Remote RN: Clinical Review & Prior Authorization

Centene Corporation; Missouri; Hybrid; USD 37,000 - 68,000; Full time

Job summary

Centene Corporation seeks a Nurse Reviewer for prior authorization in Missouri, with RN or nursing degree and 2–4 years of related experience. The role focuses on medical necessity reviews and coordination with medical teams.

Applicants may work remotely from home anywhere in Missouri. Strong knowledge of Medicare/Medicaid and utilization management preferred; the work schedule is Monday–Friday, 8am–5pm. Competitive pay and benefits.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2–4 years of related experience.
• RN with prior authorization experience preferred.

Responsibilities

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness.
• Works with providers and authorization team to ensure timely review of services and/or requests.
• Coordinates with healthcare providers and interdepartmental teams to assess medical necessity.
• Escalates prior authorization requests to Medical Directors as appropriate.
• Assists with transfer or discharge planning to ensure timely care transitions.
• Collects, documents, and maintains member clinical information in health management systems.
• Provides education to providers and interdepartmental teams on utilization processes.
• Offers feedback on opportunities to improve the authorization review process.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical reviews

Medical necessity

Utilization management

Regulatory knowledge

Education

Bachelor’s degree in Nursing

LPN license

Job description

Centene Corporation seeks a Nurse Reviewer for prior authorization in Missouri, with RN or nursing degree and 2–4 years of related experience. The role focuses on medical necessity reviews and coordination with medical teams.

Applicants may work remotely from home anywhere in Missouri. Strong knowledge of Medicare/Medicaid and utilization management preferred; the work schedule is Monday–Friday, 8am–5pm. Competitive pay and benefits.