Remote Clinical Review Nurse - Prior Authorization

Centene Corporation; Montgomery (AL); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Health insurance

401K

Tuition reimbursement

Paid time off

Holidays

Remote or flexible work options

Job summary

Centene Corporation is seeking a nursing professional to analyze prior authorization requests and determine medical necessity in alignment with regulatory guidelines and member benefits.

You will collaborate with healthcare providers and internal teams to ensure timely reviews, educate partners on utilization processes, and support transfers or discharges while maintaining high-quality, cost-effective care.

Qualifications

• Graduate from an Accredited School of Nursing or BSN with 2–4 years of related experience.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare and Medicaid regulations preferred.
• LPN license required.

Responsibilities

• Analyze prior authorization requests to determine medical necessity and appropriate level of care.
• Collaborate with healthcare providers and authorization team to ensure timely reviews.
• Escalate to Medical Directors as appropriate for determination of care.
• Collect, document, and maintain member clinical information per regulatory guidelines.
• Educate providers and interdepartmental teams on utilization processes.
• Assist with transfer or discharge planning to ensure timely care transitions.

Skills

Clinical judgment

Medical necessity analysis

Healthcare communication

Education

Licensed Practical Nurse (LPN) license

Bachelor's degree in Nursing (BSN)

Job description

Centene Corporation is seeking a nursing professional to analyze prior authorization requests and determine medical necessity in alignment with regulatory guidelines and member benefits.

You will collaborate with healthcare providers and internal teams to ensure timely reviews, educate partners on utilization processes, and support transfers or discharges while maintaining high-quality, cost-effective care.