Centene Corporation
Clinical Review Nurse - Prior Authorization
Centene Corporation, Fort Wayne, Indiana, United States, 47169
Clinical Review Nurse - Prior Authorization
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Clinical Review Nurse - Prior Authorization
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Centene Corporation
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.
Responsibilities
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 & Benefits Pay Range $26.50 – $47.59 per hour. Centene offers a comprehensive benefits package including health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off, holidays, and flexible work options.
Equal Opportunity Employer Centene is an equal opportunity employer committed to diversity and inclusion. 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 any other characteristic protected by 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
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.
Responsibilities
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 & Benefits Pay Range $26.50 – $47.59 per hour. Centene offers a comprehensive benefits package including health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off, holidays, and flexible work options.
Equal Opportunity Employer Centene is an equal opportunity employer committed to diversity and inclusion. 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 any other characteristic protected by 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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