RN Clinical Review Nurse - Prior Authorization

Centene Management Company LLC; New York (NY); Hybrid; USD 37,000 - 67,000; Full time

Benefits offered by this job

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off & holidays

Flexible work arrangements

Job summary

Centene Management Company LLC is seeking a Licensed Practical Nurse to analyze prior authorization requests and determine medical necessity in New York. You will work with healthcare providers and the authorization team to ensure timely, appropriate care and support transfer or discharge planning when needed.

The role requires an LPN license, a nursing degree, and 2–4 years of related experience. The position offers flexible work schedules including remote, hybrid, or on-site options with

Qualifications

• Graduate from an Accredited School of Nursing or BSN with 2–4 years of related experience.
• Clinical knowledge to analyze authorization requests and determine medical necessity.
• LPN license required; Fidelis Plan requires a clinical healthcare degree with the appropriate license.

Responsibilities

• Analyzes all prior authorization requests to determine medical necessity of service and level of care.
• Provides recommendations to the medical team to promote quality and cost-effective care.
• Coordinates with providers and interdepartmental teams to ensure timely reviews.
• Educates providers and teams on utilization processes to improve the authorization workflow.

Skills

Nursing

Education

Bachelor's degree in Nursing

LPN license (State Licensure)

Job description

Position Purpose

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria. Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care. Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of 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 a 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/or 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.

Education / Experience

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

License / Certification

LPN - Licensed Practical Nurse - State Licensure required. For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT.

Pay Range

Pay Range: $27.02 - $48.55 per hour

Benefits

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Diversity / Equal Opportunity

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

Company Culture

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday. Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.