Clinical Review Nurse Specialist
1 week ago
Join Centene Corporation, a leading healthcare company, as a Clinical Review Nurse and play a vital role in shaping the future of healthcare.
About the Role:We are seeking a highly skilled and experienced Clinical Review Nurse to join our Medical Management/Health Services team. As a Clinical Review Nurse, you will be responsible for analyzing prior authorization requests to determine medical necessity and appropriateness of care in accordance with national standards, contractual requirements, and member benefit coverage.
Key Responsibilities:- Analyze prior authorization requests to determine medical necessity and appropriateness of care
- Provide recommendations to the medical team to promote quality and cost-effectiveness of medical care
- Perform medical necessity and clinical reviews of authorization requests
- Work with healthcare providers and authorization teams to ensure timely review of services and requests
- Escalate prior authorization requests to Medical Directors as needed
- Assist with service authorization requests for member transfers or discharge plans
- Collect, document, and maintain member clinical information in health management systems
- Provide education to providers and interdepartmental teams on utilization processes
- Perform other duties as assigned
- 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
- Knowledge of Medicare and Medicaid regulations
- Knowledge of utilization management processes
Centene Corporation offers a comprehensive benefits package, including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off, 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.
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