Clinical Review Nurse - Prior Authorization

Centene Corporation; Illinois; Remote; USD 80,000 - 100,000; Full time

Job summary

Join a forward-thinking organization dedicated to transforming healthcare for millions. This remote role as a Clinical Review Nurse offers the opportunity to analyze prior authorization requests, ensuring quality and cost-effectiveness in medical care. You'll collaborate with healthcare providers, promote high-quality care, and contribute to improving the authorization review process. Enjoy a flexible work schedule with competitive pay and comprehensive benefits, all while making a meaningful impact in the lives of members. If you're passionate about nursing and eager to make a difference, this position is perfect for you.

Benefits

Health Insurance

401K

Stock Purchase Plans

Tuition Reimbursement

Paid Time Off

Flexible Work Schedules

Qualifications

• 2-4 years of related experience in nursing or clinical roles.
• Ability to analyze authorization requests and determine medical necessity.

Responsibilities

• Analyze prior authorization requests for medical necessity.
• Coordinate with healthcare providers for timely service reviews.
• Document and maintain clinical information in health management systems.

Skills

Clinical Review

Medical Necessity Analysis

Utilization Management

Knowledge of Medicare and Medicaid

Communication Skills

Education

Bachelor's degree in Nursing

Graduate from an Accredited School of Nursing

Job description

Clinical Review Nurse - Prior Authorization

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.

THIS POSITION IS REMOTE/WORK FROM HOME, NO TRAVEL.

MUST HOLD AN ACTIVE, CURRENT ILLINOIS LPN OR RN LICENSURE.

SCHEDULE IS MONDAY - FRIDAY 8AM - 5PM WITH ROTATIONAL HOLIDAYS AND SATURDAYS FOR 4 HOURS; YOU WOULD HAVE A HALF DAY OFF DURING THE WEEK ON EITHER TUESDAY OR WEDNESDAY WHEN YOU WORK HOLIDAY OR SATURDAY. WILL WORK CENTRAL TIME ZONE HOURS.

Position Purpose

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
• Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
• Provides feedback on opportunities to improve the authorization review process for members
• 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. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.

License/Certification

• LPN - Licensed Practical Nurse - State Licensure 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