Clinical Review Nurse - Prior Authorization at Centene

Ideal for a registered nurse with two to four years of experience and a graduate degree from an accredited nursing school. You must hold an active, unrestricted

Work type: remote

Location: Remote-NY

Salary: $27 – $49/hr

Type: Full-time

Summary

Ideal for a registered nurse with two to four years of experience and a graduate degree from an accredited nursing school. You must hold an active, unrestricted New York State RN license to be considered for this clinical role. **What makes it worth a look...** Centene offers a remote position based in New York paying between $27.02 and $48.55 per hour. You will work a consistent Monday through Friday schedule from 8:30 AM to 5:00 PM Eastern Time. **You might be a good fit if you...** * Have specific experience with utilization management and prior authorization processes. * Possess deep knowledge of Medicare and Medicaid regulatory guidelines. * Feel comfortable analyzing clinical documentation to determine medical necessity. * Can navigate health management systems to maintain accurate member records.

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.
 

Work Location
This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours.

Licensure Requirement
Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration.

Schedule
This position follows a Monday–Friday schedule from 8:30 AM to 5:00 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours.

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

• 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.

• LPN - Licensed Practical Nurse - State Licensure required

• This position is aligned to support Fidelis Care. NYS RN Licensure required.

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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