Clinical Review Nurse – Prior Authorization (RN)

Centene Corporation; United States; On-site; USD 3,722,000 - 6,688,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible remote/hybrid work options

Job summary

Centene is seeking a clinical professional for the Medical Management/Health Services team. The role analyzes all prior authorization requests to determine medical necessity and appropriate level of care, with remote work aligned to PST hours.

Responsibilities include working with providers and internal teams to ensure timely reviews, coordinating across departments, and escalating to Medical Directors when needed.

Qualifications

• Graduate from an Accredited School of Nursing or hold a BSN and 2–4 years of related experience.
• Knowledge of Medicare/Medicaid regulations preferred.
• Hospice experience preferred.
• CA RN license required.

Responsibilities

• Analyze all prior authorization requests to determine medical necessity and appropriate level of care.
• Collaborate with healthcare providers and the authorization team to ensure timely reviews.
• Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care.
• Escalate authorization requests to Medical Directors as appropriate.
• Assist with service authorization requests for transfers or discharges to ensure timely care across levels.
• Document and maintain member clinical information in health management systems.
• Educate providers and teams on utilization processes to promote high-quality, cost-effective care.
• Provide feedback to improve the authorization review process.
• Perform other duties as assigned.

Education

Nursing degree / BSN

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

• CA RN required.
• Position is remote. Will work PST hours.

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.

• 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. Hospice experience preferred.

• For Health Net of California: RN license required
• CA RN required

Pay Range: $27.02–$48.55 per hour

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