Clinical Review Nurse – Utilization & Care Coordination (Remote)

Centene Corporation; New Orleans (LA); Hybrid; USD 37,000 - 67,000; Full time

Job summary

Centene Corporation is seeking a Clinical Review Nurse to support the Ambetter team with concurrent medical necessity reviews and related duties in a Monday–Friday schedule with periodic weekend rotations. LPN or RN licensure and 2–4 years of acute care experience are preferred.

The role involves determining care level, validating medical necessity, and contributing to discharge planning in compliance with policies. Flexible work arrangements include remote, hybrid, field, or office options.

Qualifications

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2 – 4 years of related experience.
• 2+ years of acute care experience required.
• Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes 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 and/or Medical Directors as needed to discuss member care being delivered
• Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
• Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
• Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
• Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collaborates with care management on referral of members as appropriate
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical review

Utilization management

Discharge planning

Provider education

Education

Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing

2–4 years of related experience

2+ years of acute care experience

Knowledge of Medicare/Medicaid regulations

Knowledge of utilization management processes

Tools

Health management systems

Job description

Centene Corporation is seeking a Clinical Review Nurse to support the Ambetter team with concurrent medical necessity reviews and related duties in a Monday–Friday schedule with periodic weekend rotations. LPN or RN licensure and 2–4 years of acute care experience are preferred.

The role involves determining care level, validating medical necessity, and contributing to discharge planning in compliance with policies. Flexible work arrangements include remote, hybrid, field, or office options.