Senior Clinical Review Nurse - Prior Authorization

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 a RN, OT or PT

Position Purpose: 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. Assesses more complex authorization requests and 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 criteria
• Collaborates with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
• Manages service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Provides feedback on opportunities to improve the authorization review process for members
• Manages as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care
• Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
• Manages and reviews all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
• Provides education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
• Develops in-depth knowledge of the prior authorization process and acts as a trainer to other team members
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 4 – 6 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. required

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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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