Clinical Review Nurse - Concurrent Review

Centene Management Company LLC; California; Hybrid; USD 40,000 - 66,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off

Flexible work options

Job summary

Centene Management Company LLC is seeking an experienced RN to perform concurrent reviews, assess overall member health, and determine the appropriate level of care in a remote California-based role. The position follows care policies, supports discharge planning, and collaborates with Medical Affairs and providers to ensure high-quality, efficient care for members.

The ideal candidate holds a California RN license, a BSN or nursing degree, and 2–4 years of acute care experience, with knowledge

Qualifications

• Graduate from an accredited nursing program or BSN with 2–4 years of related experience.
• Minimum 2+ years of acute care experience.
• Knowledge of Medicare and Medicaid regulations and utilization management preferred.

Responsibilities

• Perform concurrent reviews to validate need and level of care.
• Collaborate with Medical Affairs/Directors on member care.
• Educate providers on utilization processes to ensure appropriate care.
• Document findings and discharge plans in health management systems.

Skills

Clinical assessment

Utilization management

Medicare/Medicaid knowledge

Acute care experience

Education

Bachelor’s degree in Nursing

Graduate from an Accredited School of Nursing

California RN license

Job description

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 is a remote position. The required schedule is Monday- Friday 8:00 am-5:00 pm Pacific Standard Time (PST) and also includes a regular weekend and holiday rotation. Must hold an active RN license in California.

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

For Health Net of California: RN license required.

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 will 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

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

EEO and Diversity Statement

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.