Clinical Review Nurse - Prior Authorization

Centene Corporation; Ohio; Remote; Full time

Job summary

A leading healthcare organization seeks a Clinical Review Nurse to analyze prior authorization requests and determine medical necessity of services. This remote role with occasional travel offers competitive benefits and aims to promote quality and cost-effective care for its members.

Benefits

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Qualifications

• Graduate from an accredited nursing program or Bachelor's in Nursing.
• 2-4 years related experience preferred.
• Preferred knowledge of Medicare/Medicaid regulations.

Responsibilities

• Analyze prior authorization requests to determine medical necessity.
• Perform medical necessity and clinical reviews.
• Coordinate with healthcare providers for timely service reviews.

Skills

Clinical knowledge

Analytical skills

Knowledge of Medicare and Medicaid regulations

Utilization management processes

Education

Graduate from an Accredited School of Nursing

Bachelor's degree in Nursing

Job description

Clinical Review Nurse - Prior Authorization

Join to apply for the Clinical Review Nurse - Prior Authorization role at Centene Corporation

Clinical Review Nurse - Prior Authorization

Join to apply for the Clinical Review Nurse - Prior Authorization role at Centene Corporation

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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.

• POSITION IS REMOTE WITH OCCASIONAL TRAVEL TO OHIO OFFICE FOR MEETINGS**
  
  

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
• RN- Preferred- Compact License
  
  

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, 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

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care and Insurance

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