Senior RN Clinical Review Nurse - Prior Authorization

Centene Corporation

1d•Hybrid

About The Position

This position is for a clinical professional on Centene's Medical Management/Health Services team, supporting the Fidelis state plan. The role involves routinely reviewing challenging prior authorization requests to determine medical necessity and appropriate level of care, adhering to national standards, contractual requirements, and member benefit coverage. The nurse assesses complex authorization requests and provides recommendations to the medical team to ensure quality and cost-effectiveness of medical care.

Requirements

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

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

Routinely reviews more challenging prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage
Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care
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