Clinical Review Nurse - Concurrent Review

Centene Corporation; Orlando (FL); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a Clinical Review Nurse to join their Medical Management team. This remote position offers the opportunity to make a significant impact on the health of 28 million members. The ideal candidate will have a strong background in utilization management and acute care, with the ability to perform concurrent reviews and collaborate with healthcare providers to ensure high-quality care. With competitive pay and comprehensive benefits, including flexible work schedules and tuition reimbursement, this role is perfect for those looking to advance their nursing career while making a difference in the lives of others.

Benefits

Health Insurance

401K

Stock Purchase Plans

Tuition Reimbursement

Paid Time Off

Flexible Work Schedules

Qualifications

• 2-4 years of related experience in nursing.
• Clinical knowledge to assess overall health and treatment needs.

Responsibilities

• Perform concurrent reviews to determine overall health and appropriate level of care.
• Collaborate with healthcare providers to approve medical determinations.

Skills

Utilization Management

Concurrent Review

Acute Care Experience

Clinical Knowledge

Medicare and Medicaid Regulations

Education

Bachelor’s degree in Nursing

Graduation from an accredited School of Nursing

Job description

Clinical Review Nurse - Concurrent Review

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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits, including a fresh perspective on workplace flexibility.

Remote-US position. Must work Eastern or Central Standard Time.

• Registered Nurse (RN) with utilization management, concurrent review, and acute care experience strongly preferred.
  

InterQual and Trucare experience a plus. Must be State Licensed.

Position Purpose

Performs concurrent reviews, including determining the 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 in evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

• Performs concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care.
• Reviews quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning.
• Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Documents and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to policies and guidelines.
• Collaborates with healthcare providers to approve medical determinations or provide recommendations based on review findings.
• Provides education to providers on utilization processes to ensure high-quality, appropriate care.
• Offers feedback to leadership on opportunities to improve appropriate level of care and medical necessity.
• Reviews member transfer or discharge plans to ensure timely discharge between levels of care and facilities.
• Collaborates with care management on member referrals as appropriate.
• Performs other duties as assigned and complies with all policies and standards.

Education/Experience

Requires graduation from an accredited School of Nursing or a Bachelor’s degree in Nursing, with 2-4 years of related experience. 2+ years of acute care experience is required. Clinical knowledge to assess overall health and treatment needs is preferred. Knowledge of Medicare and Medicaid regulations and utilization management processes is also preferred.

License/Certification

• LPN - Licensed Practical Nurse - State Licensure required.
• RN license required for Health Net of California.

Pay Range: $26.50 - $47.59 per hour.

Centene offers comprehensive benefits including competitive pay, health insurance, 401K, stock purchase plans, tuition reimbursement, paid time off, holidays, and flexible work schedules (remote, hybrid, field, or office). Actual pay depends on skills, experience, education, and other factors. Total compensation may include additional incentives.

Centene is an equal opportunity employer committed to diversity. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristic. Applicants with arrest or conviction records will be considered in accordance with applicable laws.