Remote RN: Clinical Review & Authorization

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

Benefits offered by this job

Flexible remote work

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Job summary

Centene Corporation in the United States is seeking a Licensed Practical Nurse to analyze prior authorization requests, determine medical necessity, and advise the medical team on appropriate levels of care. This role supports cost-effective, quality care across member populations and requires strong clinical judgment.

The position is full-time and can be performed remotely from home anywhere in the U.S., with occasional weekend coverage and holiday rotations to align with scheduling needs.

Qualifications

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2–4 years of related experience.
• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• 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 in accordance with regulatory guidelines and criteria.
• 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 to determine appropriateness of care.
• Assists with service authorization requests for a member’s transfer or discharge plans to ensure timely discharge between levels of care and facilities.
• Collects, documents, and maintains member clinical information in health management systems to ensure regulatory compliance.
• Provides education to providers and interdepartmental teams on utilization processes to promote high quality and cost-effective care.
• Provides feedback on opportunities to improve the authorization review process for members.

Skills

Clinical reviews

Medical necessity analysis

Regulatory knowledge

Healthcare collaboration

Education to providers

Education

Bachelor’s degree in Nursing

Graduate from an Accredited School of Nursing

Job description

Centene Corporation in the United States is seeking a Licensed Practical Nurse to analyze prior authorization requests, determine medical necessity, and advise the medical team on appropriate levels of care. This role supports cost-effective, quality care across member populations and requires strong clinical judgment.

The position is full-time and can be performed remotely from home anywhere in the U.S., with occasional weekend coverage and holiday rotations to align with scheduling needs.