Clinical Review Nurse
1 week ago
Clinical Review Nurse - Concurrent Review Join to apply for the Clinical Review Nurse - Concurrent Review role at Centene Corporation. Overview 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 and a fresh perspective on workplace flexibility. Responsibilities 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 evaluating acuity level, resource consumption, length of stay, and discharge planning. Works with Medical Affairs and/or Medical Directors 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 necessary interventions based on clinical policies and guidelines. Reviews members transfer or discharge plans to ensure 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. Job Details Schedule: MondayFriday, 8 a.m.5 p.m. Mandatory work at least one weekend day each week; preference for both weekend days. Participation in a rotational holiday schedule is required. Active compact RN license required. Education & Experience Graduate from an Accredited School of Nursing or Bachelors degree in Nursing with 24 years of related experience. 2+ years of acute care experience required. 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. Compensation and Benefits 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 schedules. Actual pay will be adjusted based on an individuals skills, experience, education, and other job-related factors permitted by law. EEO Statement Centene is an equal opportunity employer committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or 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. #J-18808-Ljbffr
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Clinical Review Nurse
4 weeks ago
Washington, United States Centene Corporation Full timeClinical Review Nurse – Concurrent Review As a member of our Medical Management/Health Services team, you will play a vital role in ensuring the highest quality care for our 28 million members. You will conduct concurrent reviews, evaluate medical necessity, and collaborate with providers and leaders to support appropriate care planning and discharge...
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Clinical Reviewer Lead
4 weeks ago
Washington, United States Comagine Health Full timevision insurance, parental leave, paid time off, remote work United States, D.C., Washington About Company: About Company: Why Comagine Health? Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line...
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Clinical Review Nurse
7 days ago
Washington, United States Centene Corporation Full timeClinical Review Nurse - Prior Authorization Join to apply for the 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...
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Clinical Reviewer, Nurse
6 days ago
Washington, DC, United States Evolent Full timeYour Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved...
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Clinical Review Specialist
7 days ago
Washington D.C., United States Healthcare Legal Solutions Full timeSUMMARY:This position is responsible for maintaining proper clinical review and interpretation of medical records and claim documentation to assist with the appeals of denied insurance claims including drafting appeal letters based on clinical judgment and knowledge.DUTIES AND RESPONSIBILITIES: Utilizes TimeMatters to obtain work assignments and communicates...
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Utilization Review Nurse
4 weeks ago
Washington, United States SPECTRAFORCE Full timeOverviewTitle: Clinical Review Nurse – Prior Authorization ReviewLocation: Fully Remote (PST Time Zone - WA/OR Resident)Duration: 12-Month (Potential for Extension)About the RoleWe are seeking an experienced Clinical Review Nurse for Prior Authorization Review to join our Utilization Management team. In this role, you will conduct concurrent and prior...
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Utilization Review Nurse
3 weeks ago
Washington, United States SPECTRAFORCE Full timeOverview Title: Clinical Review Nurse Prior Authorization Review Location: Fully Remote (PST Time Zone - WA/OR Resident) Duration: 12-Month (Potential for Extension) About the Role We are seeking an experienced Clinical Review Nurse for Prior Authorization Review to join our Utilization Management team. In this role, you will conduct concurrent and prior...
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RN: Clinical Review for Concurrent Care
1 week ago
Washington, United States Centene Corporation Full timeA leading healthcare organization is seeking a Clinical Review Nurse to perform concurrent reviews, ensuring quality care for members. The ideal candidate should possess an active RN license, 2+ years in acute care, and a background in clinical evaluation. Responsibilities include collaborating with medical professionals and maintaining accurate member...
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Clinical Reviewer III, Licensed/Remote
1 week ago
Washington, United States Remote Staffing Full timeClinical Reviewer III, Licensed/Remote (Louisiana) Conducts and oversees treatment record and case management record reviews. Trends and analyzes findings for internal and external reporting. Reviews charts and analyzes clinical record documentation. Conducts ongoing activities to monitor established quality of care standards in the participating provider...
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Clinical Reviewer, Nurse
1 week ago
Washington, United States Evolent Full timeYour Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved...
