Clinical Review Nurse - Prior Authorization
About The Position
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours. Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration. This position follows a Monday–Friday schedule from 8:30 AM to 5:00 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours.
Requirements
- Graduate 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
Nice To Haves
- Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service
- Knowledge of Medicare and Medicaid regulations
- Knowledge of utilization management processes
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
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
