RN Clinical Review Nurse — Remote/Hybrid Impact

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

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Remote, hybrid, field or office work S

Job summary

Centene Corporation is seeking a Nursing professional to analyze prior authorization requests for medical necessity and appropriate care levels. You will collaborate with providers, coordinate with care teams, and escalate complex cases to Medical Directors as needed.

The role requires a nursing degree with 2–4 years of related experience and knowledge of utilization management. Centene offers comprehensive benefits and flexible work arrangements.

Qualifications

• Clinical knowledge to analyze authorization requests and determine medical necessity.
• Knowledge of Medicare/Medicaid regulations preferred.
• Utilization management process knowledge preferred.

Responsibilities

• Analyze all prior authorization requests to determine medical necessity and appropriate level of care.
• Collaborate with healthcare providers and authorization team to ensure timely reviews.
• Coordinate with interdepartmental teams to assess medical necessity of care.
• Escalate complex cases to Medical Directors as appropriate.
• Assist with transfer/discharge planning to ensure timely progression of care.
• Maintain patient clinical information in health management systems for compliance.
• Educate providers and teams on utilization processes to promote high-quality care.
• Provide feedback to improve the review process for members.
• Perform other duties as assigned.
• Comply with all policies and standards.

Skills

Clinical knowledge

Medical necessity analysis

Regulatory knowledge

Provider communication

Education

Graduate from an Accredited School of Nursing

Bachelor’s degree in Nursing

Job description

Centene Corporation is seeking a Nursing professional to analyze prior authorization requests for medical necessity and appropriate care levels. You will collaborate with providers, coordinate with care teams, and escalate complex cases to Medical Directors as needed.

The role requires a nursing degree with 2–4 years of related experience and knowledge of utilization management. Centene offers comprehensive benefits and flexible work arrangements.