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. The position involves analyzing 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. The role includes providing recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care, performing medical necessity and clinical reviews of authorization requests, and working with healthcare providers to ensure timely review of services. Additionally, the position requires coordinating with healthcare providers and interdepartmental teams, escalating prior authorization requests to Medical Directors, assisting with service authorization requests for member transfers or discharges, and maintaining compliance with regulatory guidelines. The role also involves providing education to providers on utilization processes and feedback on opportunities to improve the authorization review process.
Responsibilities
- Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care.
- 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.
- Works with healthcare providers and authorization team to ensure timely review of services.
- Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care.
- Escalates prior authorization requests to Medical Directors as appropriate.
- Assists with service authorization requests for member transfer or discharge plans.
- Collects, documents, and maintains all member's clinical information in health management systems.
- Assists with providing education to providers and interdepartmental teams on utilization processes.
- Provides feedback on opportunities to improve the authorization review process.
- Performs other duties as assigned.
- Complies with all policies and standards.
Requirements
- Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
- 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.
- RN - Registered Nurse preferred.
Benefits
- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
