Clinical Review Nurse - Concurrent Review

Centene Corporation•Remote-MO, MO

3d•$27 - $49

About The Position

Performs concurrent reviews to assess members’ overall health, the care being delivered, medical necessity, and discharge planning in accordance with care policies and guidelines. Assists in evaluating inpatient services to validate the necessity and setting of care. The position highly prefers a Missouri RN license and post-acute care and/or utilization review experience. The role works with healthcare providers, Medical Affairs, Medical Directors, and care management to support appropriate, timely care and transitions between levels of care and facilities. It documents review findings and actions in health management systems, helps educate providers on utilization processes, and gives leadership feedback on opportunities to improve appropriate levels of care and medical necessity. Centene describes its work as connecting people to care and improving the health of individuals, families, and communities. The company offers a comprehensive benefits package, with eligibility subject to program terms. Work schedules may be remote, hybrid, field, or office; the posting does not specify the arrangement for this position.

Requirements

Graduate from an accredited school of nursing or hold a Bachelor’s degree in Nursing.
Two to four years of related experience.
At least two years of acute care experience.
LPN state licensure or RN state licensure and/or compact state licensure.

Nice To Haves

Missouri RN licensure is highly preferred.
Post-acute care experience and/or utilization review experience is highly preferred.
Clinical knowledge and ability to determine a member’s overall health, treatment needs, and appropriate level of care.
Knowledge of Medicare and Medicaid regulations.
Knowledge of utilization management processes.

Responsibilities

Perform concurrent reviews to assess members’ overall health, appropriate care, and appropriate level and setting of care.
Review quality and continuity of care, including acuity, resource consumption, length of stay, and discharge planning.
Work with Medical Affairs and/or Medical Directors as needed to discuss member care.
Collect, document, and maintain concurrent review findings, discharge plans, and actions taken in member medical records in health management systems, following utilization management policies and guidelines.
Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
Help educate providers about utilization processes to support high-quality, appropriate care.
Provide leadership with feedback on opportunities to improve appropriate levels of care and medical necessity based on clinical policies and guidelines.
Review member transfer or discharge plans to support timely transitions between levels of care and facilities.
Collaborate with care management on member referrals as appropriate.
Perform other duties as assigned.
Comply with all policies and standards.