Clinical Review Nurse - Prior Authorization

Centene Management Company LLC; Missouri; Hybrid; USD 77,424,000 - 139,116,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

tuition reimbursement

paid time off plus holidays

flexible work with remote/hybrid/field

Job summary

Centene Management Company LLC is seeking an experienced Registered Nurse to perform prior authorization reviews for medical and behavioral health services in Missouri, with remote work options. You will assess medical necessity, ensure appropriate levels of care, and collaborate with the authorization team to promote quality and cost-effective care.

The role requires an RN or BSN with 2–4 years of related experience, knowledge of Medicare/Medicaid regulations, and utilization management

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing with 2–4 years of related experience.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare and Medicaid regulations is preferred.
• Familiarity with utilization management processes is a plus.

Responsibilities

• Analyze all prior authorization requests to determine medical necessity and level of care.
• Provide recommendations to medical teams to promote quality and cost effectiveness.
• Coordinate with providers and authorization staff to ensure timely reviews.
• Escalate complex cases to Medical Directors for disposition.
• Assist with transfer or discharge planning to ensure timely transitions.
• Document and maintain member clinical data in health management systems.
• Educate providers on utilization processes to improve efficiency.
• Suggest improvements to the authorization review process.
• Comply with all policies and standards.

Skills

Registered Nurse (RN)

Utilization management

Medicare/Medicaid regulations

Clinical review

Education

Bachelor's degree in Nursing

Tools

Health management systems

Job description

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.

Key Details

Applicants for this role have the flexibility to work remotely from their home anywhere within the state of Missouri. This team performs clinical reviews for medical and behavioral health service requests for our foster care members. An RN with previous prior authorization experience is strongly preferred. The work schedule is Monday – Friday, 8am – 5pm. 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

$27.02 - $48.55 per hour

Company 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.

Benefits and Perks

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

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.