Clinical Review Nurse - Prior Authorization

Centene Management Company LLC; Texas; Híbrido; USD 37 000 - 67 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Health insurance

401K

Stock purchase plan

Tuition reimbursement

Paid time off

Resumo da oferta

Centene Corp. in Texas offers a remote RN role focused on medical necessity determinations for prior authorization requests. You will analyze clinical information, coordinate with medical teams, and ensure timely and compliant review of services.

Requirements include RN license and nursing degree, with 2–4 years of related experience. The role emphasizes education of providers and utilization process improvements to support high‑quality, cost‑effective care.

Qualificações

• Graduate from an Accredited School of Nursing or Bachelor’s in Nursing.
• 2–4 years of related experience in clinical reviews.
• Knowledge of Medicare/Medicaid regulations preferred.

Responsabilidades

• Analyzes prior authorization requests to determine medical necessity and level of care.
• Provides recommendations to medical teams to promote quality and cost effectiveness.
• Works with providers and authorization teams to ensure timely reviews.
• Escalates complex cases to Medical Directors as appropriate.
• Maintains all member clinical information in health management systems.

Conhecimentos

Clinical review & medical necessity

Regulatory knowledge

Provider collaboration

Formação académica

Nursing degree or BSN

RN license

Ferramentas

Health management systems

Descrição da oferta de emprego

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.

• Remote Role.
• Texas RN License Required.
• 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.

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: For Superior Health Plan: RN license required

Pay Range: $27.02 - $48.55 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.

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.