Clinical Review Nurse - Concurrent Review

Centene; United States; Remote; Full time

Job summary

Join a forward-thinking organization as a Clinical Review Nurse, where your expertise can make a real difference for millions. In this remote role, you will perform critical concurrent reviews, ensuring members receive the appropriate level of care. Your clinical knowledge will guide you in evaluating medical necessity and contributing to discharge planning. With a commitment to flexibility, this innovative company offers competitive pay and comprehensive benefits, allowing you to thrive in a supportive work environment. If you are passionate about healthcare and ready to take on a rewarding challenge, this opportunity is perfect for you.

Benefits

Health Insurance

401K

Stock Purchase Plans

Tuition Reimbursement

Paid Time Off

Flexible Work Schedules

Qualifications

• Requires 2-4 years of related experience in nursing with acute care.
• State licensure as an RN or LPN is required.

Responsibilities

• Perform concurrent reviews to determine member's health and care needs.
• Collaborate with healthcare providers to approve medical determinations.

Skills

Acute Care Experience

Clinical Knowledge

Utilization Management Processes

Knowledge of Medicare and Medicaid Regulations

Education

Graduate from an Accredited School of Nursing

Bachelor’s Degree in Nursing

Tools

InterQual

TruCare

Job description

Clinical Review Nurse - Concurrent Review

Pay Competitive

Location Remote

Employment type Full-Time

Job Description

• Req#: 1560462

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 acute care experience strongly preferred. InterQual and Trucare experience a plus.

State Licensed required.

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

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
• For Health Net of California: RN license required

Pay Range: $26.50 - $47.59 per hour

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. Total compensation may also include additional forms of incentives.

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.

About the company

Centene Corporation is a publicly traded managed care company based in St.