Clinical Review Nurse - Prior Authorization

Centene Corporation•Remote-NY, NY

8d•$27 - $49•Remote

About The Position

Centene is seeking a clinical professional for its Medical Management/Health Services team to analyze prior authorization requests, determine medical necessity, and ensure appropriate level of care for 28 million members. This role offers a fresh perspective on workplace flexibility and is a fully remote position requiring active New York State Registered Nurse (RN) licensure and availability to work Eastern Time hours.

Requirements

Requires a degree from an Accredited School of Nursing or Bachelor’s degree in Nursing
2 – 4 years of related experience
Active and unrestricted New York State Registered Nurse (RN) licensure is strongly preferred for consideration.
Candidates must hold active New York State Registered Nurse (RN) licensure
Candidates must be willing to work Eastern Time (ET/EST) hours.
Candidates must be able to work Monday–Friday schedule from 8:30 AM to 5:00 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break.

Nice To Haves

Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT.

Responsibilities

Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
Provides feedback on opportunities to improve the authorization review process for members
Performs other duties as assigned
Complies with all policies and standards