Clinical Review Nurse - Prior Authorization (Hospice)

Centene Corporation; Kansas; Teletrabalho; USD 65 000 - 85 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Health insurance

401K

Stock purchase plan

Tuition reimbursement

Paid time off

Resumo da oferta

Centene Corporation seeks an LPN/RN with medical necessity review experience to assess prior authorization requests and determine appropriate level of care. This full-time role offers remote work from anywhere in the United States and standard M–F hours with occasional weekend coverage in a local time zone.

You will collaborate with medical directors, providers, and internal teams to promote timely, cost effective care, document clinical information, and ensure compliance with Medicare/Medicaid

Qualificações

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

Responsabilidades

• Performs medical necessity and clinical reviews of authorization requests.
• Works with providers and authorization teams to ensure timely review of services.
• Coordinates with interdepartmental teams to assess medical necessity.
• Escalates to Medical Directors as appropriate for care appropriateness.
• Documents and maintains all member clinical information in health systems.

Conhecimentos

Clinical reviews

Utilization management

Regulatory knowledge

Provider communication

Formação académica

Bachelor's degree in Nursing

Graduate from Accredited School of Nursing

Ferramentas

Health management systems

Medicare/Medicaid guidelines

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.
Key Details: Applicants for this role have the flexibility to work remotely from their home anywhere within the United States. Full-time, Monday through Friday, 8:00 a.m. to 5:00 p.m. in the employee's local time zone. Weekend coverage is required approximately once every six weeks (Saturday and Sunday), and rotating holidays with flexible scheduling provided during the week to accommodate weekend hours worked.

• 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

Preferred qualifications include: Registered Nurse (RN) licensure with demonstrated experience in hospice and managed care environments.
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.
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