Clinical Review Nurse - Concurrent Review

Centene Corporation; Lansing (MI); Remote; USD 37,000 - 68,000; Full time

Job summary

Centene Corporation is seeking a Nurse Reviewer for remote work in the United States. The role involves performing concurrent reviews to determine appropriate level of care and discharge planning, with emphasis on medical necessity and care setting.

Requires active Nursing license and acute care experience. Ideal candidates will have knowledge of Medicare/Medicaid regulations and experience with health management systems.

Qualifications

• 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.
• Clinical knowledge to determine member health and level of care.
• Knowledge of Medicare/Medicaid regulations preferred.

Responsibilities

• Perform concurrent reviews to determine appropriate care and setting.
• Review acuity, resource use, LOS, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors on member care decisions.
• Document findings and discharge plans in health management systems.
• Educate providers on utilization processes to ensure quality care.
• Provide feedback to leadership on opportunities to improve care levels and necessity.

Skills

Nursing license

Clinical review

Utilization management

Hospital experience

Education

Bachelor's degree in Nursing

Graduate from Accredited School of Nursing

Tools

EMR systems

Job description

Business Area: Clinical & Care Management

Job Type: Full time

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. Prefer applicants who reside in either Central or Eastern Time Zones. The work schedule will be Monday - Friday 8am - 5pm based on the time zone in which you reside, and will have rotational weekends and holidays. Ideal applicant will have hospital experience, ED or acute care, hold an unencumbered compact nursing license and Michigan nursing licensure; RN preferred. The role will support Medicaid and Market Place/Ambetter members in multiple states.

• 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: $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