Senior Clinical Review Nurse - Prior Authorization

Position Purpose 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 position requires NY State licensure as an RN, OT or PT. It involves routinely reviewing more challenging 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. The role also includes assessing more complex authorization requests, providing recommendations to the appropriate medical team, performing medical necessity and clinical reviews of authorization requests, collaborating with healthcare providers and the authorization team, escalating prior authorization requests to Medical Directors as appropriate, managing service authorization requests for transfers or discharge plans, providing feedback on opportunities to improve the authorization review process, partnering with interdepartmental teams on projects, managing and reviewing all member’s clinical information in health management systems, providing education to providers and interdepartmental teams, developing in-depth knowledge of the prior authorization process, and acting as a trainer to other team members. Responsibilities Routinely reviews more challenging 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. Assess more complex authorization requests and provide recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria. Collaborate with healthcare providers and authorization team to ensure timely review of services and/or requests so members receive authorized care. Escalate prior authorization requests to Medical Directors as appropriate to determine appropriateness of care. Manage service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities. Provide feedback on opportunities to improve the authorization review process for members. Manage as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care. Partner with interdepartmental teams on projects within utilization management as part of the clinical review team. Manage and review all member’s clinical information in health management systems to ensure compliance with regulatory guidelines. Provide education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members. Develop in-depth knowledge of the prior authorization process and act as a trainer to other team members. Perform other duties as assigned. Qualifications Graduate from an accredited school of nursing or have a bachelor’s degree in nursing. Four to six years of related experience. Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Strong knowledge of Medicare and Medicaid regulations preferred. Strong knowledge of utilization management processes preferred. License/Certification For Fidelis Plan only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include nursing, PT and OT. Pay Range $30.58 – $55.09 per hour. Benefits 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 work schedules. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job‑related factors permitted by law, including full‑time or part‑time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Equal Opportunity Statement 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. 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 Centene Management Company LLC