Clinical Review Nurse - Concurrent Review

Clinical Review Nurse - Concurrent Review Be among the first 25 applicants and get AI-powered advice on this job and more exclusive features. 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. Remote-US position. Must work Eastern or Central Standard Time. Registered Nurse (RN) with utilization management, concurrent review, and acute care experience strongly preferred. InterQual and Trucare experience a plus. Must be State Licensed. Position Purpose Performs concurrent reviews, including determining the 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 in evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care. Reviews quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning. Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered. Documents and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to policies and guidelines. Collaborates with healthcare providers to approve medical determinations or provide recommendations based on review findings. Provides education to providers on utilization processes to ensure high-quality, appropriate care. Offers feedback to leadership on opportunities to improve appropriate level of care and medical necessity. Reviews member transfer or discharge plans to ensure timely discharge between levels of care and facilities. Collaborates with care management on member referrals as appropriate. Performs other duties as assigned and complies with all policies and standards. Education/Experience Requires graduation from an accredited School of Nursing or a Bachelor’s degree in Nursing, with 2-4 years of related experience. 2+ years of acute care experience is required. Clinical knowledge to assess overall health and treatment needs is preferred. Knowledge of Medicare and Medicaid regulations and utilization management processes is also preferred. License/Certification LPN - Licensed Practical Nurse - State Licensure required. RN license required for Health Net of California. Pay Range: $26.50 - $47.59 per hour. Centene offers comprehensive benefits including competitive pay, health insurance, 401K, stock purchase plans, tuition reimbursement, paid time off, holidays, and flexible work schedules (remote, hybrid, field, or office). Actual pay depends on skills, experience, education, and other factors. Total compensation may include additional incentives. Centene is an equal opportunity employer committed to diversity. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristic. Applicants with arrest or conviction records will be considered in accordance with applicable laws. #J-18808-Ljbffr