Remote RN: Medicaid Utilization Review

centene; United States; On-site; USD 37,000 - 66,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Remote work flexibility

Job summary

Centene is hiring a clinical professional for Medical Management/Health Services to support Medicaid members from a fully remote position, requiring MO RN licensure. The role emphasizes concurrent reviews, care setting determinations, and collaboration with medical leadership.

Ideal candidates have 2–4 years of acute care and managed care experience, knowledge of Medicare/Medicaid regulations, and familiarity with utilization management processes.

Qualifications

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing with 2–4 years related experience.
• Clinical knowledge to determine member health and level of care.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Performs concurrent reviews to evaluate medical necessity and appropriate level of care.
• Reviews quality and continuity of care, considering acuity, resource use, length of stay, and discharge planning.
• Collaborates with Medical Affairs/Directors to discuss member care and recommendations.
• Documents findings in health management systems and communicates with providers.
• Provides education to providers on utilization processes to ensure high-quality care.
• Gives feedback to leadership on opportunities to improve appropriate level of care.

Skills

Clinical background

Utilization management

Managed care

Acute care experience

Medicare/Medicaid knowledge

Nursing licensure

Education

Bachelor's degree in Nursing

Graduate from an Accredited School of Nursing

Tools

Health management systems

Job description

Centene is hiring a clinical professional for Medical Management/Health Services to support Medicaid members from a fully remote position, requiring MO RN licensure. The role emphasizes concurrent reviews, care setting determinations, and collaboration with medical leadership.

Ideal candidates have 2–4 years of acute care and managed care experience, knowledge of Medicare/Medicaid regulations, and familiarity with utilization management processes.