Clinical Review Nurse - Concurrent Review

Centene Corporation • Remote-IL, IL

1d • $27 - $49 • Remote

About The Position

Performs concurrent reviews, including determining members’ overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists in evaluating inpatient services to validate the necessity and setting of care being delivered to members.

This remote, work-from-home position supports Illinois Medicaid and Ambetter utilization management and requires Illinois RN licensure. The schedule is full-time, Monday through Friday, 8 a.m. to 5 p.m. Central Time, with rotating weekends and holidays.

Requirements

• Graduate from an accredited school of nursing or hold a bachelor’s degree in nursing.
• 2–4 years of related experience.
• At least 2 years of acute care experience.
• Illinois RN state licensure is required.
• LPN state licensure is listed as required.
• Ability to work Monday through Friday, 8 a.m. to 5 p.m. Central Time, with rotating weekends and holidays.

Nice To Haves

• 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 determine members’ overall health, appropriate care, and appropriate level and setting of care.
• Review quality and continuity of care by assessing acuity level, 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.
• Educate providers on utilization processes to support high-quality, appropriate care for members.
• 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 referrals of members as appropriate.
• Perform other duties as assigned.
• Comply with all policies and standards.

Benefits

• Competitive pay
• Health insurance
• 401(k)
• Stock purchase plans
• Tuition reimbursement
• Paid time off and holidays
• Flexible approach to work, including remote, hybrid, field, or office work schedules

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level