Clinical Review Nurse - Prior Authorization
: Job Details :

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. This is a remote role but must reside within New York state. 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.Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteriaWorks with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized careCoordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of memberEscalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of careAssists with service authorization requests for a member s transfer or discharge plans to ensure a timely discharge between levels of care and facilitiesCollects, documents, and maintains all member s clinical information in health management systems to ensure compliance with regulatory guidelinesAssists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to membersProvides feedback on opportunities to improve the authorization review process for membersPerforms other duties as assignedComplies with all policies and standardsEducation/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 requiredRN - Registered Nurse licensure preferredPay Range: $25.00 - $44.85 per hour 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. #J-18808-Ljbffr