Clinical Review Nurse - Concurrent Review

Centene Management Company LLC; Arizona; Híbrido; USD 37.000 - 67.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K plans

Stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible remote/hybrid/work schedules

Descripción de la vacante

Centene Management Company LLC is seeking a remote Nurse Reviewer to support Marketplace/Ambetter members across multiple states. The role involves concurrent reviews, determining appropriate level of care, discharge planning, and collaboration with Medical Affairs to ensure quality, cost-effective care.

Ideal candidates hold RN or LPN licensure, have acute care experience (acute rehab/SNF/LTC), and are eligible for licensure in required states.

Formación

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2–4 years of related experience; 2+ years acute care required.
• Knowledge of Medicare and Medicaid regulations preferred.

Responsabilidades

• Perform concurrent reviews to determine appropriate care level and setting.
• Collaborate with Medical Affairs/Medical Directors on member care decisions.
• Document and maintain concurrent review findings, discharge plans, and actions taken.
• Educate providers on utilization processes to ensure high-quality, appropriate care.

Conocimientos

Nursing licensure

Acute care experience

Inpatient discharge planning

Utilization management

Remote-work readiness

Educación

Bachelor’s degree in Nursing

Graduate from Accredited School of Nursing

Descripción del empleo

Position Purpose

Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

Key Details

This role is fully remote/work from home. The role will support our Market Place/Ambetter members in multiple states, looking for applicants who reside in either Arizona, Nevada, Oregon and Washington state. The work schedule is Monday -Friday 8am - 5pm based on the time zone in which you reside with rotational weekends and holidays. Role will support inpatient members and the ideal applicant will have acute rehab., SNF or LTC experience. RN compact nursing licensure is preferred or the ability to achieve licensures in other states as needed, cost is reimbursed by the company. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care. Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member. Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered. Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines. Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings. Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members. Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines. Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities. Collaborates with care management on referral of members as appropriate. Performs other duties as assigned. Complies with all policies and standards.

Education / Experience

Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.

License / Certification

LPN - Licensed Practical Nurse - State Licensure required RN - Registered Nurse - State Licensure and/or Compact State Licensure for State of Nevada required

Pay Range

Pay Range: $27.02 - $48.55 per hour

Benefits and Perks

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.

Diversity & Inclusion

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

Company Culture

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.