Remote Clinical Review Nurse – Utilization Management

Centene Corporation; Kansas; Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work schedules

Job summary

Centene Corporation seeks an LPN to analyze prior authorization requests and determine medical necessity for services in line with regulations and member benefits. The role supports providers and interdisciplinary teams to ensure timely authorization and high-quality care.

Remote-enabled, full-time position with weekend coverage about every six weeks and rotating holidays, all scheduling in the employee’s local time zone.

Qualifications

• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service.
• 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 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.
• Escalates prior authorization requests to Medical Directors as appropriate.
• Assists with service authorization requests for transfer or discharge plans to ensure timely discharge between levels of care.
• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
• Assists with providing education to providers and interdepartmental teams on utilization processes.
• Provides feedback on opportunities to improve the authorization review process for members.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical knowledge

Regulatory knowledge

Provider communication

Education

Graduate from Accredited School of Nursing

Bachelor’s degree in Nursing

Job description

Centene Corporation seeks an LPN to analyze prior authorization requests and determine medical necessity for services in line with regulations and member benefits. The role supports providers and interdisciplinary teams to ensure timely authorization and high-quality care.

Remote-enabled, full-time position with weekend coverage about every six weeks and rotating holidays, all scheduling in the employee’s local time zone.