RN Clinical Review Nurse - Prior Authorization

Centene Corporation•Remote-NY, NY

2d•$27 - $49

About The Position

The RN Clinical Review Nurse analyzes prior authorization requests to determine medical necessity and the appropriate level of care in accordance with 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. The nurse reviews authorization requests, coordinates with healthcare providers and internal teams to support timely decisions and authorized care, and escalates requests to Medical Directors when appropriate. The position also supports transfer and discharge authorization planning, maintains member clinical information in health management systems, educates providers and internal teams about utilization processes, and identifies opportunities to improve authorization review.

Requirements

Graduate from an accredited school of nursing or hold a Bachelor’s degree in Nursing.
Two to four years of related experience.
LPN (Licensed Practical Nurse) state licensure is required.
For the Fidelis Plan only, a clinical degree as a healthcare professional and the appropriate license are required; examples include Nursing, PT, and OT.

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 discharge between levels of care and facilities.
Collect, document, and maintain member clinical information in health management systems to ensure compliance with regulatory guidelines.
Help educate providers and interdepartmental teams on utilization processes to promote high-quality, 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.