Clinical Review Nurse - Prior Authorization

Centene Corporation•Remote-NY, NY

2d•$27 - $49•Remote

About The Position

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. This fully remote role requires an active New York RN license and the ability to work Monday through Friday, 8:30 AM to 5:00 PM ET, with a one-hour lunch break.

Requirements

Active New York RN license
Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing
2 to 4 years of related experience

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