Remote RN: Clinical Utilization & Discharge Reviewer

Centene Corporation; Phoenix (AZ); Remote; USD 37.000 - 67.000; Vollzeit

Zusammenfassung

Centene Corporation is seeking a remote Nurse Reviewer to perform concurrent reviews, assess medical necessity, and contribute to discharge planning for members across multiple states in the United States. The role prioritizes high-quality care, requires RN or LPN licensure, and offers rotation weekends/holidays with state-based licensure considerations.

Ideal candidates will have 2–4 years of acute care experience and knowledge of Medicare/Medicaid utilization management.

Qualifikationen

• Graduate from an accredited nursing program or BSN with 2–4 years of related experience.
• RN/LPN licensure in applicable states; Nevada compact license preferred.
• Knowledge of Medicare/Medicaid and utilization management processes preferred.

Aufgaben

• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care.
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member.
• Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members.
• Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines.
• Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborates with care management on referral of members as appropriate.
• Performs other duties as assigned.
• Complies with all policies and standards.

Kenntnisse

Concurrent reviews

Discharge planning

Utilization management

Provider education

Clinical knowledge

Ausbildung

Bachelor’s degree in Nursing

Graduate from an Accredited School of Nursing

Tools

RN licensure

LPN licensure

Jobbeschreibung

Centene Corporation is seeking a remote Nurse Reviewer to perform concurrent reviews, assess medical necessity, and contribute to discharge planning for members across multiple states in the United States. The role prioritizes high-quality care, requires RN or LPN licensure, and offers rotation weekends/holidays with state-based licensure considerations.

Ideal candidates will have 2–4 years of acute care experience and knowledge of Medicare/Medicaid utilization management.