Remote Clinical Review Nurse - Utilization & Care

Centene Corporation; Town of Florida (NY); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Remote work flexibility

Job summary

Centene Corporation is seeking a licensed practical nurse (LPN) to analyze prior authorization requests for medical necessity and the appropriate level of care. You will collaborate with providers and the authorization team to ensure timely reviews and authorized care aligned with regulatory guidelines and member benefits.

This full-time role allows remote work from anywhere in the United States, with weekend coverage approximately once every six weeks and rotating holidays.

Qualifications

• Requires LPN license (state licensure).
• Bachelor’s degree in Nursing preferred; RN licensure preferred.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare/Medicaid regulations and utilization management preferred.

Responsibilities

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care.
• Works with providers and authorization team to ensure timely review and delivery of authorized care.
• Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care.
• Escalates requests to Medical Directors to determine appropriateness of care.
• Assists with discharge planning to ensure timely transfer between levels of care and facilities.
• Collects and maintains member clinical information in health management systems per regulatory guidelines.
• Provides education to providers and teams on utilization processes to promote cost-effective care.
• Offers feedback to improve the authorization review process for members.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education

Bachelor’s degree in Nursing

Graduate from an Accredited School of Nursing

Job description

Centene Corporation is seeking a licensed practical nurse (LPN) to analyze prior authorization requests for medical necessity and the appropriate level of care. You will collaborate with providers and the authorization team to ensure timely reviews and authorized care aligned with regulatory guidelines and member benefits.

This full-time role allows remote work from anywhere in the United States, with weekend coverage approximately once every six weeks and rotating holidays.