Clinical Review Nurse-Prior Authorization

Centene•Austin, PA

6d•$27 - $49•Remote

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. Centene is hiring a Remote Clinical Review Nurse - Prior Authorization to support our Duals team . The ideal candidate will have experience reviewing outpatient services , with a background in one or more of the following areas: Imaging services Durable Medical Equipment (DME) Home Health Care Elective inpatient services This role is responsible for conducting clinical reviews for prior authorization requests in accordance with medical necessity guidelines, regulatory requirements, and company policies. This is a remote position with standard business hours, Monday through Friday, 8:00 AM-5:00 PM, (EST or CST) with potential for weekend, holiday, and on-call coverage.

Requirements

Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
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.
LPN - Licensed Practical Nurse - State Licensure required

Responsibilities

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage.
Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
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