Clinical Review Nurse - Prior Authorization (Hospice)

Centene Corporation•Remote-FL, MO

1d•Remote

About The Position

The Clinical Review Nurse analyzes prior authorization requests to determine medical necessity and the appropriate level of care in accordance with national standards, contractual requirements, and member benefit coverage. The role provides recommendations to the appropriate medical team to promote quality and cost-effective care. This is a remote position that may be performed from the employee’s home anywhere in the United States. The regular schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. in the employee’s local time zone. Weekend coverage is required approximately once every six weeks, including Saturday and Sunday, along with rotating holidays. Flexible weekday scheduling is provided to accommodate weekend hours worked. The position requires graduation from an accredited school of nursing or a bachelor’s degree in nursing, along with 2–4 years of related experience. A state LPN license is required. RN licensure and demonstrated hospice and managed care experience are preferred. Centene offers competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off and holidays, and flexible work arrangements. Benefits may be subject to eligibility. Pay and total compensation depend on individual job-related factors and may include incentives.

Requirements

Graduate from an accredited school of nursing or a bachelor’s degree in nursing.
2–4 years of related experience.
State licensure as a Licensed Practical Nurse (LPN).

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.
Registered Nurse (RN) licensure.
Demonstrated experience in hospice and managed care environments.

Responsibilities

Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
Work with healthcare providers and the authorization team to ensure timely review of services and requests so members receive authorized care.
Coordinate with healthcare providers and interdepartmental teams, as appropriate, to assess the medical necessity of member care.
Escalate prior authorization requests to Medical Directors, as appropriate, to determine appropriateness of care.
Assist with service authorization requests for member transfer or discharge plans to ensure timely discharge between levels of care and facilities.
Collect, document, and maintain member clinical information in health management systems to ensure compliance with regulatory guidelines.
Educate providers and interdepartmental teams on utilization processes to promote high-quality, cost-effective medical care.
Provide feedback on opportunities to improve the authorization review process for members.
Perform other duties as assigned.
Comply with all policies and standards.