Clinical Review Nurse - Concurrent Review

Centene Corporation; Austin (TX); Presencial; USD 37.000 - 67.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off

Flexible work schedules

Descripción de la vacante

Centene seeks a licensed nurse to perform concurrent reviews of inpatient admissions for pediatric and adult members within the LA Medicaid line of business. The role focuses on determining medical necessity and appropriate level of care, with standard hours 8am to 5pm CST and weekend/holiday rotation.

Requires a nursing degree and state licensure with 2+ years of acute care experience. Knowledge of Medicare/Medicaid regulations and utilization management is preferred.

Formación

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

Responsabilidades

• Perform concurrent reviews of inpatient admissions to validate necessity and level of care.
• Collect, document, and maintain concurrent review findings and discharge plans.
• Collaborate with Medical Affairs and care management on recommendations.
• Educate providers on utilization processes to ensure high-quality care.
• Ensure timely discharge planning between levels of care and facilities.

Conocimientos

Clinical reviews

Acute care

Utilization management

Medicare/Medicaid

Educación

Bachelor's degree in 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. 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.

Key Details

This position will be responsible for conducting clinical reviews of inpatient medical admissions for both pediatric and adult members within the LA Medicaid line of business. Standard hours are 8am - 5pm CST with weekend and holiday rotation.

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

Pay Range

$27.02 - $48.55 per hour

About Centene

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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.

Equal Opportunity Employer

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.

Disability and Background Consideration

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act