Senior Clinical Review Nurse - Retrospective Review

Centene Corporation • Northampton, MA

2d • $31 - $55 • Remote

About The Position

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs a clinical retrospective review and assessment of complex services previously provided to determine if the level of care and services provided were clinically appropriate. Provides observations and recommendations to senior management for quality-of-care issues identified to ensure services were administered with quality, cost efficiency, and are within compliance. Performs a clinical review and assessment of relevant complex post-care services by reviewing medical records against guidelines and clinical research criteria to determine if the services administered were clinically appropriate and within quality standards at the most efficient and effective level Reviews medical records for medical necessity of services to identify quality of care issues and, if identified, refer to the Medical Director for review and verification Applies clinical knowledge to ensure compliance with medical necessity guidelines, medical policy, and accepted standards of care Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Collaborates and consults with senior management and healthcare providers, as appropriate, for any discrepancies between prior authorization and concurrent review processes to ensure clinically appropriate determinations Provides education to providers on utilization processes to promote high quality, cost-effective, and efficient medical care to members Partners on opportunities to improve the retrospective review process for members and to ensure high quality of care Performs other duties as assigned Complies with all policies and standards Location: Remote (Must be able to work in Central Time Zone) We are seeking candidates with strong experience in payment integrity and utilization review.

Requirements

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 4 – 6 years of related experience.
• LPN - Licensed Practical Nurse - State Licensure required

Nice To Haves

• Advanced clinical knowledge and ability to analyze medical records to determine care services provided were appropriate preferred.
• Strong knowledge of Medicare and Medicaid regulations preferred.
• Strong knowledge of utilization management processes preferred.

Responsibilities

• Performs a clinical retrospective review and assessment of complex services previously provided to determine if the level of care and services provided were clinically appropriate.
• Provides observations and recommendations to senior management for quality-of-care issues identified to ensure services were administered with quality, cost efficiency, and are within compliance.
• Performs a clinical review and assessment of relevant complex post-care services by reviewing medical records against guidelines and clinical research criteria to determine if the services administered were clinically appropriate and within quality standards at the most efficient and effective level
• Reviews medical records for medical necessity of services to identify quality of care issues and, if identified, refer to the Medical Director for review and verification
• Applies clinical knowledge to ensure compliance with medical necessity guidelines, medical policy, and accepted standards of care
• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
• Collaborates and consults with senior management and healthcare providers, as appropriate, for any discrepancies between prior authorization and concurrent review processes to ensure clinically appropriate determinations
• Provides education to providers on utilization processes to promote high quality, cost-effective, and efficient medical care to members
• Partners on opportunities to improve the retrospective review process for members and to ensure high quality of care
• Performs other duties as assigned
• Complies with all policies and standards

Benefits

• Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.
• Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.
• Total compensation may also include additional forms of incentives.
• Benefits may be subject to program eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees