Clinical Review Nurse - Concurrent Review
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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. Applicants have the flexibility to work remotely from their home anywhere in the Central time zone in the US. The work schedule is Monday – Friday, 8 am – 5 pm with a couple holidays per year. Previous concurrent review experience using InterQual is preferred. The position requires a Kansas nursing license or compact license.
Responsibilities
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.
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
Assists with providing education to providers on utilization processes to ensure high‑quality appropriate care to members.
Provides feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines.
Reviews member’s transfer or discharge plans to ensure a timely transition between levels of care and facilities.
Collaborates with care management on referral of members as appropriate.
Performs other duties as assigned.
Complies with all policies and standards.
Education & Experience
Requires a graduate credential from an accredited school of nursing or a bachelor’s degree in nursing plus 2–4 years of related experience; at least 2 years of acute care experience is required. Clinical knowledge and the ability to determine overall health of a member—including treatment needs and appropriate level of care—are preferred. Knowledge of Medicare and Medicaid regulations and utilization‑management processes is also preferred.
License / Certification
LPN – Licensed Practical Nurse – State licensure required.
Pay
$26.50 – $47.59 per hour.
Benefits
Competitive pay
Health insurance
401 K and stock purchase plans
Tuition reimbursement
Paid time off and holidays
Flexible approach to work with remote, hybrid, field or office schedules
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 protected characteristics. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.