Clinical Review Nurse - Remote Utilization Expert

Centene Corporation; Missouri; Hybrid; USD 37,000 - 66,000; Full time

Job summary

Centene Corporation is seeking a Nursing professional to perform concurrent reviews, ensuring appropriate care settings and medical necessity for members. The role includes documenting findings, collaborating with Medical Affairs, and educating providers on utilization processes.

Requires MO RN licensure with 2–4 years of related experience and 2+ years of acute care. Pay range listed; outpatient, remote or hybrid work options may be available.

Qualifications

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

Responsibilities

• Performs concurrent reviews to determine appropriate care and setting.
• Reviews acuity level, resource use, length of stay, and discharge planning.
• Collaborates with Medical Affairs/Medical Directors as needed.
• Documents concurrent review findings in health management systems.
• Educates providers on utilization processes to ensure high quality care.
• Provides feedback to leadership on opportunities to improve care and medical necessity.
• Reviews transfer or discharge plans for timely discharge between levels of care.
• Collaborates with care management on referrals.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Utilization management

Acute care

Clinical knowledge

Education

Bachelor's degree in Nursing

Graduate from Accredited School of Nursing

Tools

Health management systems

Job description

Centene Corporation is seeking a Nursing professional to perform concurrent reviews, ensuring appropriate care settings and medical necessity for members. The role includes documenting findings, collaborating with Medical Affairs, and educating providers on utilization processes.

Requires MO RN licensure with 2–4 years of related experience and 2+ years of acute care. Pay range listed; outpatient, remote or hybrid work options may be available.