Clinical Review Nurse - Concurrent Review

Centene Management Company LLC; Pennsylvania; Hybrid; USD 37,000 - 67,000; Full time

Job summary

Centene Management Company LLC is seeking a licensed Practical Nurse (LPN) or Registered Nurse (RN) for remote case management in Pennsylvania. The role focuses on concurrent reviews to verify appropriate care levels and medical necessity, with collaboration across Medical Affairs and physicians.

Requires active PA or Compact State licensure and 2+ years in acute care. Prior experience with utilization management and familiarity with MCG/InterQual criteria are a plus.

Qualifications

• Must be a licensed RN or LPN with active state licensure.
• 2+ years of acute care experience preferred.
• Knowledge of Medicare/Medicaid regulations and utilization processes is a plus.

Responsibilities

• Perform concurrent reviews to assess care level and medical necessity.
• Collaborate with Medical Affairs/Medical Directors on member care.
• Document findings, discharge plans, and actions in health systems.
• Educate providers on utilization processes to ensure quality care.
• Support timely discharge and coordinate transfers between care settings.

Skills

Case management

Utilization management (UM)

Utilization review (UR)

MCG criteria

InterQual criteria

Education

Bachelor's degree in Nursing

Graduate from an Accredited School of Nursing

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.

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.

Key Details

Remote role. Seeking a Licensed Practical Nurse (LPN) or Registered Nurse (RN) with an active Pennsylvania or Compact State license. Schedule is Monday through Friday, 8:00 AM to 5:00 PM. Previous Case Management, Utilization Management (UM), or Utilization Review (UR) experience is highly preferred. Experience with MCG and/or InterQual criteria is a plus.

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 & Pay

LPN - Licensed Practical Nurse - State Licensure required. RN - Registered Nurse - State Licensure and/or Compact State Licensure. Pay Range: $27.02 - $48.55 per hour.

Employer 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 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.

Equal Opportunity

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.