Clinical Review Nurse - Prior Authorization

Centene
New York
Workplace: RemoteFull timeUSD 27.02 - 48.55 hourlyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 2-4 yearsEducation: bachelorsSkills: ["Clinical review","Medical necessity analysis","Utilization management","Cross-functional coordination","Process improvement"]

Review prior authorization requests to determine medical necessity and appropriate level of care for members, using national standards, contractual requirements, and regulatory guidelines. Conduct medical necessity and clinical reviews, coordinate timely reviews with healthcare providers and authorization teams, escalate cases to Medical Directors when appropriate, and maintain member clinical information in health management systems to support quality and cost-effective care.

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FursaFursa
Centene
Centene
1 day ago

Clinical Review Nurse - Prior Authorization

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Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 10 hours agoStatus: Live
Reposted: similar role first listed 6 months ago

Job Summary

Review prior authorization requests to determine medical necessity and appropriate level of care for members, using national standards, contractual requirements, and regulatory guidelines. Conduct medical necessity and clinical reviews, coordinate timely reviews with healthcare providers and authorization teams, escalate cases to Medical Directors when appropriate, and maintain member clinical information in health management systems to support quality and cost-effective care.
Location: New York
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Analyze prior authorization requests to determine medical necessity and appropriate level of care.
  • •Conduct medical necessity and clinical reviews based on regulatory guidelines and criteria.
  • •Work with healthcare providers and the authorization team to ensure timely review of services and requests.
  • •Coordinate with healthcare providers and interdepartmental teams to assess medical necessity of care.
  • •Escalate prior authorization requests to Medical Directors as appropriate and maintain member clinical information in health management systems.

Pay and Benefits

Salary: USD 27.02 - 48.55 hourly
Perks:Health Insurance401kEquityPaid Leave

Key Requirements

  • •Active and unrestricted New York State Registered Nurse (RN) licensure is required.
  • •Graduate from an accredited school of nursing or a Bachelor’s degree in Nursing.
  • •2–4 years of related experience.
  • •Strong clinical knowledge to analyze authorization requests and determine medical necessity (preferred).
  • •Familiarity with Medicare and Medicaid regulations and utilization management processes (preferred).
Experience:2-4 years
Education:Bachelor's
Skills:Clinical reviewMedical necessity analysisUtilization managementCross-functional coordinationProcess improvement
Licenses:New York State Registered Nurse (RN) licensureActive and unrestricted New York State RN licensure
Tech Stack:Health management systems

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn