Remote Clinical Review Nurse: Utilization & Authorization

Centene Corporation; Iowa; Remote; USD 65,000 - 80,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Job summary

Centene Corporation seeks a Licensed Practical Nurse (LPN) with a nursing background to conduct medical necessity reviews for prior authorization requests. The role supports reimbursement and patient care decisions across the US, with a remote-friendly schedule and weekend coverage on a rotating basis.

Requires a nursing degree and state licensure, plus 2–4 years of related experience. RN qualifications are preferred and healthcare regulation knowledge is advantageous.

Qualifications

• Clinical knowledge and ability to analyze authorization requests to determine medical necessity.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care.
• Works with healthcare providers to ensure timely review of services to ensure members receive authorized care.
• Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care.
• Escalates prior authorization requests to Medical Directors as needed to determine appropriateness of care.
• Assists with service authorization requests for transfers or discharge plans to ensure timely discharge.
• Collects and maintains all member clinical information in health management systems in compliance with regulations.
• Provides education to providers and interdepartmental teams on utilization processes to promote high-quality care.
• Provides feedback on opportunities to improve the authorization review process.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical knowledge

Analyze authorization requests

Utilization management knowledge

Education

Accredited nursing program

Bachelor’s degree in Nursing

Job description

Centene Corporation seeks a Licensed Practical Nurse (LPN) with a nursing background to conduct medical necessity reviews for prior authorization requests. The role supports reimbursement and patient care decisions across the US, with a remote-friendly schedule and weekend coverage on a rotating basis.

Requires a nursing degree and state licensure, plus 2–4 years of related experience. RN qualifications are preferred and healthcare regulation knowledge is advantageous.