Clinical Review Nurse - Concurrent Review

Centene Corporation; Dallas (TX); On-site; Full time

Job summary

A leading healthcare organization seeks a Clinical Review Nurse to perform concurrent reviews and assess patient care. The role involves collaboration with medical staff, documentation of findings, and ensuring compliance with care policies. Candidates should have a nursing degree and relevant clinical experience, with strong communication and critical thinking skills. This position offers a flexible work schedule and competitive benefits.

Benefits

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off

Flexible work schedule

Qualifications

• 2+ years of acute care experience required.
• Knowledge of Concurrent Review and Utilization Management processes preferred.

Responsibilities

• Performs concurrent reviews to determine overall health and appropriate level of care.
• Collaborates with healthcare providers to approve medical determinations.
• Documents findings and maintains records according to policies.

Skills

Clinical knowledge

Critical thinking

Multi-tasking

Communication

Education

Bachelor’s degree in Nursing

Graduate from an Accredited School of Nursing

Tools

Microsoft Office

CMS databases

EMR databases

Job description

Clinical Review Nurse - Concurrent Review

Clinical Review Nurse - Concurrent Review

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.

Work Schedule Monday - Friday 800 am - 500 pm (CST)

Position Required To Work In Central Time Zone

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
  
  

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.

License/Certification

• LPN - Licensed Practical Nurse - State Licensure is required
• RN - Registered Nurse - State Licensure and/or Compact Nursing Licensure is required
  
  

Preferred Experience

• 3+ years’ of direct patient care experience as a Registered Nurse (RN) in Acute Care – Trauma, Critical Care, ICU, ER, Cardiac, L & D, Med/Surg, OR, Oncology, OB/Gyn, Military, LTC, SNF, Surgery, Telemetry, Triage Nursing, Urgent Care, and/or Women’s Health
• 3+ years of clinical nursing experience with all patient populations (0 – 65+) providing care coordination, D/C planning, patient and family education, and patient safety
• Role requires clinical experience, knowledge, and the ability to determine overall health of members, including treatment needs and appropriate level of care
• Knowledge of Concurrent Review, Utilization Management processes, Medicare, Medicaid, and Managed Care is preferred
• Strong computer skills and experience working within multiple CMS and EMR databases
• Strong multi-tasking and critical thinking skills required in this role to communicate with Medical Directors, clinical staff, members, and providers
• Must be able to navigate between multiple screens, Microsoft Office applications and utilize multiple avenues of communication (e.g. phone queue, MS Teams, email, video conferencing) - 90% of the role responsibilities.
  
  

Pay Range $26.50 - $47.59 per hour

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. Total compensation may also include additional forms of incentives.

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

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care and Insurance

Referrals increase your chances of interviewing at Centene Corporation by 2x

Sign in to set job alerts for “Registered Nurse” roles.

Healthcare Appeals Clinician RN - Remote $10K sign on bonus

Registered Nurse (Remote) - Oncology Abstractor

Clinical Appeal Nurse - Remote $10K Sign on Bonus

RN/Registered Nurse Supervisor, Virtual Care Delivery, Full time, Evenings

Dallas, TX $115,000.00-$125,000.00 2 months ago

Nurse Practitioner or Physician Assistant for Virtual Health Services

Sr Hospice Clinical Learning and Development Specialist-Registered Nurse

Registered Nurse - RN / Progressive Care Unit - TELE-P

Registered Nurse - RN / Progressive Care Unit - TELE-P

Registered Nurse - RN / Progressive Care Unit - TELE-P

RN, Senior LTSS Service Care Manager - Remote

Dallas-Fort Worth Metroplex $120,000.00-$130,000.00 2 weeks ago

Nurse Practitioner or Physician Assistant - Mobile Wound Care Specialist (Dallas-Fort Worth)

Advanced Surgical Consultant - Dallas/Ft. Worth

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.