Senior Clinical Review Nurse - Prior Authorization

Centene Corporation•Remote-NY, NY

1d•$31 - $55•Hybrid

About The Position

This position is for a Senior Clinical Review Nurse on the Medical Management/Health Services team. The role involves reviewing challenging prior authorization requests to determine the medical necessity of services and the appropriate level of care, adhering to national standards, contractual requirements, and member benefit coverage. The nurse will assess complex authorization requests and provide recommendations to the medical team to ensure quality and cost-effectiveness of medical care. This role requires NY State Licensure as a RN, OT or PT.

Requirements

NY State Licensure as a RN, OT or PT
Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
4 – 6 years of related experience

Nice To Haves

Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service
Strong knowledge of Medicare and Medicaid regulations
Strong knowledge of utilization management processes

Responsibilities

Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
Collaborates with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
Manages service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
Provides feedback on opportunities to improve the authorization review process for members.
Manages as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care.
Partners with interdepartmental teams on projects within utilization management as part of the clinical review team.
Manages and reviews all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
Provides education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
Develops in-depth knowledge of the prior authorization process and acts as a trainer to other team members.
Performs other duties as assigned.
Complies with all policies and standards.