Clinical Review Nurse - Prior Authorization (Hospice)

Centene Corporation; Tallahassee (FL); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health insurance

401K plan

Tuition reimbursement

Paid time off

Remote work options

Job summary

Centene Corporation seeks a Nurse Reviewer to analyze prior authorization requests and determine medical necessity in line with regulatory guidelines and member benefits. You will collaborate with medical directors, providers, and the authorization team to ensure timely care and appropriate levels of service.

Remote-friendly role within the United States, full-time, Monday–Friday with occasional weekend coverage as described.

Qualifications

• RN with Bachelor's in Nursing and 2–4 years of related experience.
• Knowledge of Medicare/Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Analyze prior authorization requests to determine medical necessity.
• Coordinate with healthcare providers and authorization team to ensure timely reviews.
• Escalate cases to Medical Directors as appropriate.
• Maintain member clinical information in health management systems.
• Educate providers on utilization processes to improve care.

Skills

Nursing

RN licensure

Clinical reviews

Utilization management

Education

Bachelor’s degree in Nursing

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.