Clinical Review Nurse - Prior Authorization (Hospice)

Centene Corporation; United States; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health insurance

401K and stock plans

Tuition reimbursement

Paid time off and holidays

Flexible remote/hybrid schedules

Job summary

Centene Corporation seeks an experienced RN to analyze prior authorization requests from a remote location within the United States. The role evaluates medical necessity and appropriate level of care in line with national standards and contract requirements.

You will recommend coverage decisions to the medical team, support utilization management, and work with flexible scheduling including occasional weekend hours. Requires RN licensure and 2–4 years of related experience.

Qualifications

• RN licensure and active state license in good standing.
• 2–4 years of related nursing experience.
• Experience analyzing prior authorization requests preferred.

Responsibilities

• Analyzes all prior authorization requests to determine medical necessity and appropriate level of care.
• Provides recommendations to the medical team to promote quality and cost effectiveness.
• Collaborates with interdisciplinary teams to support utilization management decisions.
• Works remotely from the United States with weekend coverage rotating on occasional basis.

Skills

Clinical assessment

Medicare/Medicaid knowledge

Utilization management

Remote collaboration

Education

RN degree (BSN or equivalent)

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.

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