Remote Clinical Review Nurse – Prior Authorization

Centene Corporation; Missouri; Remote; USD 65,000 - 90,000; Full time

Job summary

Centene Corporation is seeking a nurse to analyze prior authorization requests for medical necessity and appropriate level of care. The role supports coordination with providers and medical teams to ensure timely, cost-effective care across the United States.

The position offers full-time hours, remote work from anywhere in the U.S., with weekend coverage approximately every six weeks and occasional holidays. LPN or RN licensure is required, with RN preferred for hospice/ managed care experience.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing with 2–4 years of related experience.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• LPN license required (state licensure)

Responsibilities

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care.
• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
• Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care for members.
• Escalates prior authorization requests to Medical Directors as appropriate.
• Assists with service authorization requests for a member’s transfer or discharge plans to ensure timely discharge between levels of care and facilities.
• Collects, documents, and maintains all member’s clinical information in health management systems to ensure regulatory compliance.
• Provides education to providers and interdepartmental teams on utilization processes to promote high quality and cost-effective care.
• Provides feedback on opportunities to improve the authorization review process for members.
• Performs other duties as assigned and complies with all policies and standards.

Skills

Clinical knowledge

Analytical skills

Provider communication

Education

Bachelor’s degree in Nursing

Graduate from Accredited School of Nursing

Tools

Health information systems

Job description

Centene Corporation is seeking a nurse to analyze prior authorization requests for medical necessity and appropriate level of care. The role supports coordination with providers and medical teams to ensure timely, cost-effective care across the United States.

The position offers full-time hours, remote work from anywhere in the U.S., with weekend coverage approximately every six weeks and occasional holidays. LPN or RN licensure is required, with RN preferred for hospice/ managed care experience.