Clinical Review Nurse - Concurrent Review

Centene Management Company LLC; New York (NY); Hybrid; USD 37,000 - 67,000; Full time

Benefits offered by this job

Health insurance

401K

Stock purchase plan

Tuition reimbursement

Paid time off

Job summary

Centene Management Company LLC is seeking a remote RN reviewer to perform concurrent reviews, determine appropriate level of care, and support discharge planning for members. Strong preference for an active NY RN license; typical hours are Mon-Fri 8:30 AM–5:00 PM ET, with a one-hour lunch.

Responsibilities include reviewing acuity, resource use, and discharge planning, collaborating with Medical Affairs, and educating providers on utilization processes to ensure high-quality care.

Qualifications

• Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing, plus 2 to 4 years of related experience.
• 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.

Responsibilities

• Perform concurrent reviews to determine appropriate care and setting.
• Assess acuity level, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors on member care.
• Document and maintain concurrent review findings and discharge plans.
• Educate providers on utilization processes to ensure quality care.
• Provide feedback to leadership on improvement opportunities for care levels.

Skills

RN License

Utilization management

Medicare/Medicaid knowledge

Clinical assessment

Education

BSN degree

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 fully remote role strongly prefers candidates with an active and unrestricted New York State Registered Nurse (RN) license. Candidates must be able to work Monday through Friday, 8:30 AM to 5:00 PM ET, with a one-hour lunch break.
• 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

• Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing, plus 2 to 4 years of related experience.
• 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
• This position is aligned to support Fidelis Care.
• NYS RN licensure strongly preferred.

Pay Range

$27.02 - $48.55 per hour

Company Culture

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 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.

Benefits

• 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.