Clinical Review Nurse - Concurrent Review

Centene Corporation; Illinois; Hybrid; USD 37,000 - 67,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Job summary

Centene Corporation is seeking an experienced RN for utilization management in Illinois. The role focuses on concurrent reviews to determine appropriate level of care, validates medical necessity, and supports discharge planning.

Remote work from home is offered with standard M-F hours, some weekends/holidays rotation. The ideal candidate will have an Illinois RN license, a nursing degree, 2–4 years of related experience, and knowledge of Medicare/Medicaid regulations.

Qualifications

• Requires RN licensure in Illinois.
• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing with 2–4 years of related experience.
• 2+ years of acute care experience required.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Performs concurrent reviews to determine appropriate level of care and setting.
• Review acuity, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors as needed.
• Document findings and discharge plans in health management systems.
• Coordinate with providers to approve determinations or provide recommendations.
• Educate providers on utilization processes to ensure high quality care.
• Provide feedback on improvements to involvement/throughput.
• Review transfer/discharge plans for timely progression between levels of care.

Skills

Utilization management

Clinical assessment

Acute care experience

Interdisciplinary collaboration

Education

RN license in Illinois

Bachelor’s degree in Nursing

Accredited nursing program graduate

Tools

Electronic Health Records (EHR)

Health management systems

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.

Key Details: This position is remote/work from home and will support Illinois Medicaid and Ambetter utilization management. The position requires an Illinois RN licensure.

The role is full-time, work hours are Monday - Friday, 8am - 5pm central time zone, and rotating weekends and holidays.

• 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 Licensue required
• RN - Registered Nurse - State Licensure the State of Illinois is required

Pay Range: $27.02 - $48.55 per hour

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.

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.

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