Clinical Review Nurse — Remote/Hybrid

Centene Corporation; New Jersey; Hybrid; USD 37,000 - 67,000; Full time

Job summary

Centene Corporation is seeking a Nurse Reviewer to perform concurrent reviews, assessing member health, care setting, and medical necessity. The role collaborates with Medical Affairs to discuss care and supports discharge planning with documentation in health management systems.

The ideal candidate holds a nursing degree with 2–4 years of related experience, acute care exposure, and familiarity with Medicare/Medicaid regulations.

Qualifications

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2–4 years of related experience.
• 2+ years of acute care experience is required.
• Knowledge of Medicare and Medicaid regulations preferred.

Responsibilities

• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care.
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member.
• Works with Medical Affairs/Medical Directors to discuss member care.
• Collects and maintains concurrent review findings and discharge plans in health management systems.
• Collaborates with care management on referral of members as appropriate.
• Provides education to providers on utilization processes to ensure high quality appropriate care.

Skills

Concurrent reviews

Nursing knowledge

Utilization management

Discharge planning

Provider education

Education

Bachelor’s degree in Nursing

Tools

Health management systems

Job description

Centene Corporation is seeking a Nurse Reviewer to perform concurrent reviews, assessing member health, care setting, and medical necessity. The role collaborates with Medical Affairs to discuss care and supports discharge planning with documentation in health management systems.

The ideal candidate holds a nursing degree with 2–4 years of related experience, acute care exposure, and familiarity with Medicare/Medicaid regulations.