Clinical Review Nurse - Prior Authorization

Centene Corporation•Remote-NY, NY

6d•$27 - $49•Remote

About The Position

The Clinical Review Nurse analyzes prior authorization requests to determine medical necessity and the appropriate level of care according to national standards, contractual requirements, regulatory guidelines, and members’ benefit coverage. The role provides recommendations to the appropriate medical team to promote quality and cost-effective medical care. This is a fully remote position requiring an active New York RN license, with hours Monday through Friday, 8:30 AM to 5:00 PM ET and a one-hour lunch break. The nurse works with healthcare providers and authorization and interdepartmental teams to coordinate timely reviews and authorized care. The position also supports transfer and discharge authorization requests, maintains clinical information in health management systems, provides education on utilization processes, and offers feedback to improve authorization reviews.

Requirements

Active New York RN license.
Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing.
2 to 4 years of related experience.

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 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 support timely transitions 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/or interdepartmental teams on utilization processes to promote high-quality and 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.