Clinical Review Nurse - Concurrent Review

Centene Corporation • Remote-NC, NC

1d • $27 - $49

About The Position

Performs concurrent reviews to determine members’ overall health, assess the type and setting of care being delivered, evaluate medical necessity, and contribute to discharge planning in accordance with care policies and guidelines. Assists in evaluating inpatient services to validate the necessity and setting of care. The role requires residence in the Eastern Time Zone.

Works with healthcare providers, Medical Affairs, Medical Directors, and care management to support appropriate care and timely transitions between levels of care and facilities. Documents review findings, discharge plans, and actions in health management systems according to utilization management policies and guidelines. Provides education to providers on utilization processes and feedback to leadership on opportunities to improve care appropriateness and medical necessity.

Requirements

• Graduate of an accredited school of nursing or a Bachelor’s degree in Nursing.
• 2–4 years of related experience.
• At least 2 years of acute care experience.
• LPN — Licensed Practical Nurse — state licensure required.
• Must reside in the Eastern Time Zone.

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 the care being delivered to members.
• Collect, document, and maintain concurrent review findings, discharge plans, and actions taken in member medical records in health management systems according to utilization management policies and guidelines.
• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assist in educating providers on utilization processes to support high-quality, appropriate care for members.
• Provide feedback to leadership 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) and stock purchase plans.
• Tuition reimbursement.
• Paid time off and holidays.
• Flexible approach to work, with remote, hybrid, field, or office work schedules.
• Additional forms of incentives may be included in total compensation.

What This Job Offers

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