Clinical Review Nurse - Utilization & Discharge Planning

Centene Corporation; Mississippi; Hybrid; USD 56,000 - 101,000; Full time

Job summary

Centene Corporation in Mississippi seeks a nurse to perform concurrent reviews and evaluate medical necessity for inpatient admissions and procedures, supporting the Magnolia Health Plan Utilization Management team. The role emphasizes assessing overall member health, care settings, and discharge planning per policy.

Ideal candidates hold an RN/LPN qualification with 2–4 years of acute care experience, familiarity with Medicare/Medicaid rules, and the ability to educate providers on utilization

Qualifications

• 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 and care level.
• Knowledge of Medicare/Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Performs concurrent reviews to determine appropriate care and level of care.
• Reviews quality and continuity of care by analyzing acuity, resource use, LOS, and discharge planning.
• Collaborates with Medical Affairs/Medical Directors on member care discussions.
• Documents and maintains concurrent review findings and discharge plans in care management systems.
• Works with providers to approve medical determinations or provide recommendations.
• Educates providers on utilization processes to ensure quality care.
• Provides leadership feedback to improve medically necessary care.
• Reviews transfer or discharge plans for timely transitions between care levels.

Skills

Acute care experience

Clinical knowledge

Utilization management processes

Education

Bachelor's degree in Nursing

Graduate from Accredited School of Nursing

LPN - Licensed Practical Nurse

Job description

Centene Corporation in Mississippi seeks a nurse to perform concurrent reviews and evaluate medical necessity for inpatient admissions and procedures, supporting the Magnolia Health Plan Utilization Management team. The role emphasizes assessing overall member health, care settings, and discharge planning per policy.

Ideal candidates hold an RN/LPN qualification with 2–4 years of acute care experience, familiarity with Medicare/Medicaid rules, and the ability to educate providers on utilization