Remote Clinical Review Nurse: Utilization & Authorization

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

Benefits offered by this job

Tuition reimbursement

Health insurance

401K and stock purchase plans

Job summary

Centene Corporation is seeking a Nurse Reviewer to analyze prior authorization requests to determine medical necessity and appropriate level of care, in alignment with regulatory guidelines and member benefits.

You will collaborate with healthcare providers and internal teams to ensure timely, appropriate authorization decisions and maintain accurate clinical documentation across health management systems.

Qualifications

• Graduate from an Accredited School of Nursing or a Bachelor’s degree in Nursing with 2–4 years of related experience.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare/Medicaid regulations and utilization management processes is preferred.

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.
• Coordinates with healthcare providers and interdepartmental teams to assess medical necessity.
• Escalates prior authorization requests to Medical Directors as appropriate.
• Assists with service authorization requests for transfers or discharges to ensure timely care.
• Maintains member clinical information in health management systems to ensure regulatory compliance.
• Educates providers and teams on utilization processes to promote high quality, cost-effective care.
• Provides feedback on opportunities to improve the authorization review process.
• Performs other duties as assigned and complies with all policies.

Skills

Medical reviews

Regulatory knowledge

Nursing clinical judgment

Communication

Team collaboration

Education

Accredited School of Nursing or BSN

LPN license

RN licensure preferred

Job description

Centene Corporation is seeking a Nurse Reviewer to analyze prior authorization requests to determine medical necessity and appropriate level of care, in alignment with regulatory guidelines and member benefits.

You will collaborate with healthcare providers and internal teams to ensure timely, appropriate authorization decisions and maintain accurate clinical documentation across health management systems.