Centene Corporation
Clinical Review Nurse - Prior Authorization
Centene Corporation, New York, New York, United States
Clinical Review Nurse - Prior Authorization
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Clinical Review Nurse - Prior Authorization
role at
Centene Corporation
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.
Applicants for this role have the flexibility to work remotely from their home anywhere in the United States.
This position does require an Oregon RN or LPN license.
The work schedule for the position is Monday – Friday, 8 am – 5 pm Pacific, with occasional weekends and holidays.
Position Purpose
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.
Pay Range: $26.50 – $47.59 per hour
Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) 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.
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.
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Clinical Review Nurse - Prior Authorization
role at
Centene Corporation
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.
Applicants for this role have the flexibility to work remotely from their home anywhere in the United States.
This position does require an Oregon RN or LPN license.
The work schedule for the position is Monday – Friday, 8 am – 5 pm Pacific, with occasional weekends and holidays.
Position Purpose
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.
Pay Range: $26.50 – $47.59 per hour
Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) 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.
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.
#J-18808-Ljbffr