Clinical Review Nurse - Prior Authorization

Centene Corporation•Remote-TX, TX

16h•$27 - $49•Remote

About The Position

The Clinical Review Nurse analyzes prior authorization requests to determine medical necessity and the appropriate level of care, following national standards, contractual requirements, regulatory guidelines, and members’ benefit coverage. The role provides recommendations to the appropriate medical team to promote high-quality, cost-effective medical care. This is a remote role, and an RN license for Texas is required; for Superior Health Plan, an RN license is required. The nurse reviews authorization requests, coordinates with providers and internal teams to support timely authorization decisions, and escalates requests to Medical Directors when appropriate. The role also supports transfer and discharge planning, maintains clinical records in health management systems, and helps educate providers and teams on utilization processes. Other duties may be assigned, and the position must comply with applicable policies and standards.

Requirements

Graduate from an accredited school of nursing or hold a bachelor’s degree in nursing.
2–4 years of related experience.
RN license required for Superior Health Plan; the role details also state that a Texas RN license is required.

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

Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness 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 members’ 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 support timely discharge between levels of care and facilities.
Collect, document, and maintain members’ clinical information in health management systems to ensure compliance with regulatory guidelines.
Assist in educating providers and interdepartmental teams about utilization processes to promote high-quality, cost-effective care.
Provide feedback on opportunities to improve the authorization review process for members.
Perform other duties as assigned.
Comply with all policies and standards.