Clinical Review Nurse - Concurrent Review at Centene

Ideal candidates are nurses with a degree from an accredited nursing program or a Bachelor’s in Nursing, holding an active LPN or RN license. You must have at l

Work type: remote

Location: Remote-AZ

Salary: $27 – $49/hr

Type: Full-time

Summary

Ideal candidates are nurses with a degree from an accredited nursing program or a Bachelor’s in Nursing, holding an active LPN or RN license. You must have at least two years of acute care experience and a strong background in clinical review. **What makes it worth a look...** Centene offers a pay range of $27.02 to $48.55 per hour for this fully remote role. Employees receive a comprehensive benefits package that includes a 401K, stock purchase plans, and tuition reimbursement. **You might be a good fit if you...** * Hold an active RN or LPN license. * Possess at least two years of acute care experience. * Have proficiency in utilizing InterQual or similar medical necessity tools. * Live in the Central or Mountain time zones.

Job Description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 

Seeking a remote Clinical Review Nurse to perform UM Clinical reviews for post-acute levels of care (Skilled Nursing, Inpatient Rehab, LTACH) utilizing medical necessity tools (InterQual) and clinical policies.

Candidates in CST or MST are highly preferred

Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

• 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.

Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification:

• LPN - Licensed Practical Nurse - State Licensure required


• RN - Registered Nurse - State Licensure and/or Compact State Licensure

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.

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