Clinical Review Nurse - Concurrent Review

Centene Corporation; Washington; Híbrido; USD 37 000 - 67 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work arrangement

Resumo da oferta

Centene Corporation is hiring a nurse reviewer to perform concurrent reviews for Medicaid and Marketplace post-acute care from a fully remote role. Ideal candidates reside in Central, Mountain, or Pacific Time Zones and hold compact licensure with 5+ years of nursing experience, including LTACH/IPR/SNF settings.

Typical schedule is Mon–Fri, 8am–5pm based on your time zone with rotating Saturdays and holidays. Eligible for competitive pay and benefits.

Qualificações

• Nursing degree or equivalent and active licensure in nursing.
• 2–4 years of related nursing experience with 2+ years acute care experience.
• Knowledge of Medicare/Medicaid regulations and utilization management preferred.

Responsabilidades

• Perform concurrent reviews to determine appropriate level of care.
• Review acuity, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors as needed.
• Document findings and discharge plans in health management systems.
• Assist providers with utilization processes and educate on requirements.
• Provide feedback to leadership on care improvements.
• Review transfer/discharge plans to ensure timely transitions.
• Collaborate on referrals as appropriate.
• Perform other duties as assigned.
• Comply with all policies and standards.

Formação académica

Graduate from Accredited School of Nursing or Bachelor’s degree in Nursing

LPN - Licensed Practical Nurse State Licensure

RN - Registered Nurse State Licensure/Compact State Licensure

Descrição da oferta de emprego

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 position is fully remote/work from home, and will support Medicaid and Market Place/Ambetter members for Post Acute Care. Looking for applicants who reside in either Central Time Zone, Mountain Time Zone or Pacific Time Zone and ideally hold a compact nursing licensure. Experience should include LTACH, IPR or SNF experience with a minimum of 5 years nursing experience. The work schedule will be Monday-Friday 8am - 5pm based on the time zone in which you reside, and will have rotational Saturdays and holidays.

• 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 Licensure For State of Nevada required

Pay Range: $27.02 - $48.55 per hour

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.

• competitive pay


• health insurance


• 401K and stock purchase plans


• tuition reimbursement


• paid time off plus holidays


• 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