Clinical Review Nurse - Prior Authorization (Hospice)

Centene Corporation; Montgomery (AL); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Health insurance

401K

Tuition reimbursement

Paid time off

Holidays

Remote or flexible work options

Job summary

Centene Corporation is seeking a nursing professional to analyze prior authorization requests and determine medical necessity in alignment with regulatory guidelines and member benefits.

You will collaborate with healthcare providers and internal teams to ensure timely reviews, educate partners on utilization processes, and support transfers or discharges while maintaining high-quality, cost-effective care.

Qualifications

• Graduate from an Accredited School of Nursing or BSN with 2–4 years of related experience.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare and Medicaid regulations preferred.
• LPN license required.

Responsibilities

• Analyze prior authorization requests to determine medical necessity and appropriate level of care.
• Collaborate with healthcare providers and authorization team to ensure timely reviews.
• Escalate to Medical Directors as appropriate for determination of care.
• Collect, document, and maintain member clinical information per regulatory guidelines.
• Educate providers and interdepartmental teams on utilization processes.
• Assist with transfer or discharge planning to ensure timely care transitions.

Skills

Clinical judgment

Medical necessity analysis

Healthcare communication

Education

Licensed Practical Nurse (LPN) license

Bachelor's degree in Nursing (BSN)

Job description

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 utilisation 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.

Additional Information:

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.

Benefits:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

EEO/EEU Statement:

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.