Clinical Review Nurse - Prior Authorization

Centene; Texas; Teletrabalho; USD 37 000 - 67 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Resumo da oferta

Centene is seeking a Clinical Review Nurse - Prior Authorization for a remote position based in Texas. This role focuses on analyzing authorization requests to determine medical necessity and appropriate levels of care, leveraging utilization management knowledge and regulatory guideline understanding.

The position offers remote work with full-time hours, competitive hourly pay, and benefits. The ideal candidate will have RN licensure, 2–4 years of related experience, and the ability to educate

Qualificações

• RN licensure required and active
• 2–4 years of related nursing experience in utilization management or prior authorization
• Knowledge of medical necessity reviews and regulatory guidelines

Responsabilidades

• Analyze prior authorization requests for medical necessity and appropriate level of care.
• Collaborate with providers and authorization teams for timely reviews.
• Coordinate with interdepartmental teams to assess medical necessity and escalate as needed.
• Educate providers and teams on utilization processes and feedback on process improvements.
• Maintain and document member clinical information in health management systems.
• Comply with all policies and standards.

Formação académica

Graduate from Accredited School of Nursing

Bachelor's degree in Nursing

Descrição da oferta de emprego

About This Role

The Clinical Review Nurse - Prior Authorization analyzes prior authorization requests to determine medical necessity and appropriate levels of care. This remote position is ideal for nurses with experience in utilization management and a strong understanding of regulatory guidelines.

Highlights

• Pay: $27.02 - $48.55 per hour
• Location: Remote, TX
• Schedule: Full Time

What You'll Do

• Perform medical necessity and clinical reviews of authorization requests.
• Work with healthcare providers and authorization team for timely service reviews.
• Coordinate with healthcare providers and interdepartmental teams to assess medical necessity.
• Escalate prior authorization requests to Medical Directors as needed.
• Assist with service authorization requests for member transfers or discharges.
• Collect, document, and maintain member clinical information in health management systems.
• Educate providers and interdepartmental teams on utilization processes.
• Provide feedback on opportunities to improve the authorization review process.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements

Education

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing

Experience

• 2 – 4 years of related experience

Licenses & Certifications

• RN license required

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work schedules

About Centene

Centene is a leading healthcare provider committed to delivering exceptional patient care. They connect people to the care they need to live healthier lives, supporting individuals, families, and communities through meaningful challenges.