Clinical Review Nurse - Concurrent Review

Centene Management Company LLC; New Jersey; 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 + holidays

Remote/hybrid/field or office work

Job summary

Centene Management Company LLC is seeking an LPN to perform concurrent reviews, assess the member's overall health, and determine appropriate care setting and level of care. You will review inpatient services for medical necessity and contribute to discharge planning.

You will collaborate with Medical Affairs/Medical Directors, educate providers on utilization processes, document findings, and ensure timely transfers or discharges while adhering to policies.

Qualifications

• 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.
• LPN - Licensed Practical Nurse license required.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Performs concurrent reviews to determine overall health and appropriate level of care.
• Reviews acuity level, resource consumption, length of stay, and discharge planning.
• Collaborates with Medical Affairs/Medical Directors to discuss member care.
• Maintains concurrent review findings, discharge plans, and actions in health management systems.
• Assists providers with approvals or recommendations based on concurrent review findings.
• Provides education to providers on utilization processes to ensure high-quality care.
• Offers feedback to leadership on opportunities to improve appropriate level of care and medical necessity.
• Reviews transfer/discharge plans for timely discharge between levels of care and facilities.

Skills

Clinical assessment

Care coordination

Utilization review

Discharge planning

Inpatient care knowledge

Education

Graduate from an Accredited School of Nursing or BSN

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:

Must reside in EST or CST. Med Surg experience highly preferred. 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

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
• 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.

Centene is committed to helping people live healthier lives.

We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.