Clinical Review Nurse-Prior Authorization

Centene Corporation; Orlando (FL); Remote; USD 80,000 - 100,000; Full time

Job summary

An innovative healthcare organization is seeking a Clinical Review Nurse to join their Medical Management team. In this pivotal role, you will analyze prior authorization requests, ensuring compliance with medical necessity standards and promoting quality care. With a focus on collaboration, you will work closely with healthcare providers and internal teams to streamline processes and enhance patient outcomes. This position offers the flexibility of remote work, competitive pay, and a comprehensive benefits package, making it an excellent opportunity for those looking to make a significant impact in the healthcare industry.

Benefits

Health Insurance

401K

Tuition Reimbursement

Paid Time Off

Flexible Work Options

Qualifications

• 2-4 years of experience in clinical review and authorization processes.
• Knowledge of Medicare/Medicaid regulations and utilization management.

Responsibilities

• Analyze prior authorization requests for medical necessity.
• Collaborate with healthcare providers for timely reviews.
• Educate providers on utilization processes.

Skills

Clinical Review

Medical Necessity Analysis

Collaboration with Healthcare Providers

Utilization Management

Education

Bachelor's Degree in Nursing

Graduate from Accredited Nursing School

Tools

Health Management Systems

Job description

Clinical Review Nurse-Prior Authorization

Join us as a Clinical Review Nurse-Prior Authorization at Centene Corporation.

Be part of our Medical Management/Health Services team, impacting the lives of 28 million members. We offer flexible workplace arrangements and competitive benefits.

Positions Available: 8
Work Location: Remote/Work from Home supporting Medicare utilization for outpatient, DME, home health, and medical prior authorizations.
Schedule: Monday - Friday, 8 AM - 5 PM in your time zone, with a weekend rotation every 4-6 weeks (either Saturday or Sunday), with a weekday off.

Position Purpose

Analyze prior authorization requests to determine medical necessity and appropriate care levels, ensuring compliance with standards, contractual requirements, and member benefits. Provide recommendations to medical teams to promote quality and cost-effective care.

• Perform medical necessity and clinical reviews of authorization requests
• Collaborate with healthcare providers and authorization teams for timely reviews
• Coordinate with providers and interdepartmental teams to assess medical necessity
• Escalate requests to Medical Directors when needed
• Assist with discharge and transfer authorization requests
• Maintain all clinical information in health management systems
• Educate providers and teams on utilization processes
• Suggest improvements to the authorization review process
• Perform additional duties as assigned
• Comply with all policies and standards

Qualifications

Graduate from an accredited nursing school or possess a Bachelor's degree in Nursing with 2-4 years of related experience. Clinical knowledge in authorization review and understanding of Medicare/Medicaid regulations are preferred. Knowledge of utilization management processes is also preferred.

• License: LPN - Licensed Practical Nurse with state licensure

Pay Range

$26.50 - $47.59 per hour

Benefits

Comprehensive package including competitive pay, health insurance, 401K, stock purchase plans, tuition reimbursement, paid time off and holidays, and flexible work options (remote, hybrid, field, or office).

Equal Opportunity

Centene is committed to diversity and equal employment opportunity. All qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics. Applicants with arrest or conviction records will be considered in accordance with applicable laws.