Clinical Review Nurse-Concurrent Review

Overview Applicants must have and maintain an active New York State (NYS) RN licensure to be considered. The standard fully remote work schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. EST with coverage on one of two holidays. Responsibilities Perform 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. Assist in evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Conduct concurrent reviews to determine appropriate care setting and level of care. Review quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning. Work with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered. Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines. Collaborate with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings. Assist in educating providers on utilization processes to ensure high‑quality appropriate care to members. Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines. Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities. Collaborate with care management on referral of members as appropriate. Perform other duties as assigned. Qualifications Graduation from an accredited school of nursing or a Bachelor’s degree in Nursing (BSN). 2–4 years of related nursing experience, with a minimum of 2 years in acute care. Clinical knowledge and ability to determine overall health of member, including treatment needs and appropriate level of care. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License / Certification LPN – Licensed Practical Nurse – State Licensure required; NYS RN Licensure strongly preferred. Pay Range $27.02 – $48.55 per hour. Benefits Competitive pay Health insurance 401(k) and stock purchase plans Tuition reimbursement Paid time off plus holidays Flexible approach to work with remote, hybrid, field, or office schedules Equal Employment Opportunity 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 any other characteristic protected by applicable 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