Clinical Review Nurse
4 weeks ago
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
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. Total compensation may also include additional forms of incentives.
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.
-
Clinical Review Nurse I
1 month ago
Atlanta, Georgia, United States Elevance Health Full timeClinical Review Nurse I - Medicare Part ANational Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.Location:This is a virtual position and preferred candidates reside within 50 miles...
-
Utilization Review Nurse
13 hours ago
Atlanta, Georgia, United States Sidecar Health Full timeAbout the RoleAs a Utilization Review Nurse at Sidecar Health, you will play a critical role in evaluating the medical necessity and quality of healthcare services for our members. This involves reviewing medical records, ensuring compliance with established clinical guidelines and policies, and collaborating with healthcare providers to gather additional...
-
Clinical Review Specialist
5 days ago
Atlanta, Georgia, United States Sonder Health Plans Full timeJob Description:The Clinical Review Specialist role at Sonder Health Plans is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance.By continuously reviewing and auditing member treatment records, the Clinical Review Specialist will ensure members do not receive unnecessary procedures, ineffective treatment,...
-
Nurse Reviewer
3 days ago
Atlanta, United States Zelis Full timePosition OverviewThe Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical records...
-
Nurse Reviewer
7 days ago
Atlanta, United States Zelis Full timePosition OverviewThe Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical records...
-
Medical Claims Review Nurse
1 month ago
Atlanta, United States KARNA LLC Full timeJob DescriptionJob DescriptionDescription:Are you passionate about making a difference? The World Trade Center (WTC) Health Program provides support to those impacted by 9/11. This position for a medical claims review nurse on the World Trade Center (WTC) Health Program will have a direct impact on members of the program. The nurse will be responsible for...
-
Utilization Review Nurse
4 weeks ago
Atlanta, United States Sonder Health Plans, Inc. Full timeJob Description: The Utilization Review Nurse's role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective treatment, or experience...
-
Utilization Review Nurse
2 months ago
Atlanta, Georgia, United States Sonder Health Plans, Inc. Full timeJob Description:The Utilization Review Nurse's role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective treatment, or experience...
-
Utilization Review Nurse
3 months ago
Atlanta, United States Sonder Health Plans Full timeJob DescriptionJob DescriptionJob Description:The Utilization Review Nurse’s role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective...
-
Clinical Logistics Nurse
4 days ago
Atlanta, United States Core Clinical Management LLC Full timeJob DescriptionJob DescriptionDescription:The Clinical Logistics Nurse (CLN) is a member of the Core Clinical Partners Clinical Operations Department, responsible for delivery of Core’s process designed to improve quality and efficiency in the care of hospitalized patients. The CLN collaborates closely with Medical Directors to engage and educate the...
-
Medical Necessity Reviewer
5 days ago
Atlanta, Georgia, United States Piedmont Full timeJob Summary:Piedmont is seeking a highly skilled Clinical Appeals Specialist to join our team. As a Clinical Appeals Specialist, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key Responsibilities:Conduct detailed reviews of patient medical...
-
Medical Necessity Reviewer
5 days ago
Atlanta, Georgia, United States Piedmont Healthcare Corporate Full timeJob SummaryPiedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key ResponsibilitiesConduct detailed reviews of...
-
Medical Necessity Reviewer
5 days ago
Atlanta, Georgia, United States Piedmont Healthcare Corporate Full timeAbout the Role:Piedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key Responsibilities:Conduct detailed...
-
Clinical Nurse Leader Medical Surgical
5 days ago
Atlanta, Georgia, United States Clinical Management Consultants Full timeJob SummaryWe are seeking a highly experienced and skilled Nurse Director to lead our Medical Surgical Unit. As a key member of our leadership team, you will be responsible for driving excellence in patient care, team collaboration, and operational efficiency.Key ResponsibilitiesLead a team of Medical Surgical RNs in providing high-quality patient...
-
Medical Reviewer
2 weeks ago
Atlanta, United States Careerbuilder-US Full timeJob Title: Medical Reviewer Location: Remote Duration: 12 Months+ ROLE RESPONSIBILITIES: · Works with study team to ensure high quality of data is maintained by assisting with data review (per data review plan) assigned and overseen by the supervising medical monitor in the study. · Data review could be safety or efficacy or...
-
Healthcare Claims Review Specialist
2 weeks ago
Atlanta, United States KARNA LLC Full timePosition OverviewAre you dedicated to enhancing healthcare outcomes? KARNA LLC is seeking a skilled Medical Claims Review Nurse to contribute to our mission of supporting individuals affected by significant health events. This role is pivotal in ensuring that claims are meticulously reviewed for medical necessity and in addressing provider appeals...
-
Utilization Review Nurse
1 month ago
Atlanta, United States GHR Healthcare Full timeAre you a detail-oriented RN with a knack for navigating complex medical cases? Do you thrive on making critical decisions that impact patient care? Join us as a Care Management Coordinator and play a key role in evaluating and authorizing essential healthcare services. Shift: Monday – Friday (8am – 5pm Normal business hours) Type: Temp to...
-
Utilization Review Nurse
1 month ago
Atlanta, United States GHR Healthcare Full timeAre you a detail-oriented RN with a knack for navigating complex medical cases? Do you thrive on making critical decisions that impact patient care? Join us as a Care Management Coordinator and play a key role in evaluating and authorizing essential healthcare services. Shift: Monday – Friday (8am – 5pm Normal business hours) Type: Temp to...
-
Utilization Review Nurse
4 weeks ago
Atlanta, United States GHR Healthcare Full timeAre you a detail-oriented RN with a knack for navigating complex medical cases? Do you thrive on making critical decisions that impact patient care? Join us as a Care Management Coordinator and play a key role in evaluating and authorizing essential healthcare services. Shift: Monday - Friday (8am - 5pm Normal business hours) Type: Temp to Hire...
-
Clinical Logistics Nurse
3 days ago
Atlanta, Georgia, United States Core Clinical Management LLC Full timeJob Description**Job Summary:**We are seeking a highly skilled Clinical Logistics Nurse to join our team at Core Clinical Management LLC. As a Clinical Logistics Nurse, you will play a critical role in improving the quality and efficiency of care for hospitalized patients.Key Responsibilities:Process Improvement: Collaborate with Medical Directors to develop...
