Remote RN: Clinical Review & Prior Authorization

Centene Corporation; Missouri; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health insurance

401K plan

Tuition reimbursement

Paid time off

Flexible work arrangements

Job summary

Centene Corporation is seeking a Nurse Reviewer to analyze prior authorization requests to determine medical necessity and appropriate level of care. The role supports timely reviews in collaboration with healthcare providers and the authorization team, with a flexible remote schedule within the United States.

Requires nursing licensure and 2–4 years of related experience, with preferred knowledge of Medicare/Medicaid regulations and utilization management processes.

Qualifications

• Graduate from an Accredited School of Nursing or BSN with 2–4 years of related experience.
• 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 for the member.
• Escalates prior authorization requests to Medical Directors as appropriate 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 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 to promote high quality and cost-effective medical care to members.
• Provides feedback on opportunities to improve the authorization review process for members.
• Performs other duties as assigned
• Complies with all policies and standards

Skills

Nursing knowledge

Clinical analysis

Utilization management

Communication skills

Education

Bachelor's degree in Nursing

Job description

Centene Corporation is seeking a Nurse Reviewer to analyze prior authorization requests to determine medical necessity and appropriate level of care. The role supports timely reviews in collaboration with healthcare providers and the authorization team, with a flexible remote schedule within the United States.

Requires nursing licensure and 2–4 years of related experience, with preferred knowledge of Medicare/Medicaid regulations and utilization management processes.