Clinical Review Nurse - Retrospective Review

Centene Corporation • Northampton, MA

1d • $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. Position Purpose: Performs a clinical retrospective review of services previously provided to determine if the level of care and services provided were clinically appropriate. Provides observations to senior management for quality-of-care issues identified to ensure services were administered with quality, cost efficiency, and are within compliance. Performs a clinical review of post-care services by reviewing medical records against guidelines and clinical research criteria to determine if the services administered were clinically appropriate and within quality standards at the most efficient and effective level Reviews medical records for medical necessity of services, to identify quality of care issues, and if identified, refer to the Medical Director or provider for review and verification Consults with senior management and healthcare providers, as appropriate, for any discrepancies between prior authorization and concurrent review processes to ensure clinically appropriate determinations 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 on utilization processes to promote high quality, cost-effective, and efficient medical care to members Provides feedback on opportunities to improve the retrospective review process for members and to ensures high quality care Performs other duties as assigned Complies with all policies and standards Location: Remote (Must be able to work in Central Time Zone) Ideal candidate will have experience in payment integrity and utilization review.

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 medical records to determine care services provided were appropriate preferred.
• LPN - Licensed Practical Nurse - State Licensure required

Nice To Haves

• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• Ideal candidate will have experience in payment integrity and utilization review.

Responsibilities

• Performs a clinical retrospective review of services previously provided to determine if the level of care and services provided were clinically appropriate.
• Provides observations to senior management for quality-of-care issues identified to ensure services were administered with quality, cost efficiency, and are within compliance.
• Performs a clinical review of post-care services by reviewing medical records against guidelines and clinical research criteria to determine if the services administered were clinically appropriate and within quality standards at the most efficient and effective level
• Reviews medical records for medical necessity of services, to identify quality of care issues, and if identified, refer to the Medical Director or provider for review and verification
• Consults with senior management and healthcare providers, as appropriate, for any discrepancies between prior authorization and concurrent review processes to ensure clinically appropriate determinations
• 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 on utilization processes to promote high quality, cost-effective, and efficient medical care to members
• Provides feedback on opportunities to improve the retrospective review process for members and to ensures high quality care
• Performs other duties as assigned
• Complies with all policies and standards

Benefits

• Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees