Clinical Review Nurse - Concurrent Review

Centene Corp.; North Carolina; Remote; USD 37,000 - 67,000; Full time

Job summary

Centene Corp. is seeking a Clinical Review Nurse to conduct concurrent reviews and validate the appropriateness of care, benefits, and discharge planning. This fully remote role supports continuity of care for members in North Carolina, working Monday through Friday with rotating weekends.

Ideal candidates have 2+ years of acute care nursing and prior UM/CM experience, with RN or LPN licensure. Knowledge of Medicare/Medicaid regulations is preferred and familiarity with UM processes is a plus.

Qualifications

• 2+ years of acute care nursing experience required.
• Minimum 2 years of acute care experience; Utilization Management (UM) and/or Case Management (CM) experience preferred.
• Licensure as RN or LPN is required; state licensure or compact state licensure accepted.

Responsibilities

• Perform concurrent reviews to determine appropriate level of care and overall member health.
• Review acuity level, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors on care decisions and recommendations.
• Document and maintain concurrent review findings, discharge plans, and actions in health records.

Skills

Acute care nursing

Utilization management

Case management

Medicare/Medicaid knowledge

Clinical assessment

Education

Graduate from an Accredited School of Nursing

Bachelor’s degree in Nursing

Job description

## Clinical Review Nurse - Concurrent ReviewApply: Remote-NC: Full time: Posted Today: 1658806**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 is a fully remote position working Monday through Friday with a rotating weekend schedule. Candidates must have a minimum of two years of acute care nursing experience. Previous Utilization Management (UM) and/or Case Management (CM) experience is 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* RN - Registered Nurse - State Licensure and/or Compact State LicensurePay Range: $27.02 - $48.55 per hour