Remote RN: Medical Necessity & Prior Authorization

Centene Management Company LLC; Missouri; Hybrid; USD 77,424,000 - 139,116,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

tuition reimbursement

paid time off plus holidays

flexible work with remote/hybrid/field

Job summary

Centene Management Company LLC is seeking an experienced Registered Nurse to perform prior authorization reviews for medical and behavioral health services in Missouri, with remote work options. You will assess medical necessity, ensure appropriate levels of care, and collaborate with the authorization team to promote quality and cost-effective care.

The role requires an RN or BSN with 2–4 years of related experience, knowledge of Medicare/Medicaid regulations, and utilization management

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing with 2–4 years of related experience.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare and Medicaid regulations is preferred.
• Familiarity with utilization management processes is a plus.

Responsibilities

• Analyze all prior authorization requests to determine medical necessity and level of care.
• Provide recommendations to medical teams to promote quality and cost effectiveness.
• Coordinate with providers and authorization staff to ensure timely reviews.
• Escalate complex cases to Medical Directors for disposition.
• Assist with transfer or discharge planning to ensure timely transitions.
• Document and maintain member clinical data in health management systems.
• Educate providers on utilization processes to improve efficiency.
• Suggest improvements to the authorization review process.
• Comply with all policies and standards.

Skills

Registered Nurse (RN)

Utilization management

Medicare/Medicaid regulations

Clinical review

Education

Bachelor's degree in Nursing

Tools

Health management systems

Job description

Centene Management Company LLC is seeking an experienced Registered Nurse to perform prior authorization reviews for medical and behavioral health services in Missouri, with remote work options. You will assess medical necessity, ensure appropriate levels of care, and collaborate with the authorization team to promote quality and cost-effective care.

The role requires an RN or BSN with 2–4 years of related experience, knowledge of Medicare/Medicaid regulations, and utilization management