Clinical Review Nurse - Prior Authorization (RN)

Centene
California
Workplace: RemoteFull timeUSD 27.02 - 48.55 hourlyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 2-4 yearsEducation: bachelorsSkills: ["Communication","Documentation","Attention to detail","Process improvement"]

Analyze prior authorization requests to determine medical necessity and appropriate level of care for members, following national standards, contractual requirements, and benefit coverage. Perform clinical and medical necessity reviews, coordinate with healthcare providers and authorization teams for timely decisions, and escalate cases to Medical Directors when needed. Document and maintain clinical information in health management systems, support service authorization for transfers/discharges, and provide utilization education while improving the authorization review process.

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FursaFursa
Centene
Centene
1 day ago

Clinical Review Nurse - Prior Authorization (RN)

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Source: Company careers pageValidated by: Fursa AI
Last checked: 11 hours agoStatus: Live

Job Summary

Analyze prior authorization requests to determine medical necessity and appropriate level of care for members, following national standards, contractual requirements, and benefit coverage. Perform clinical and medical necessity reviews, coordinate with healthcare providers and authorization teams for timely decisions, and escalate cases to Medical Directors when needed. Document and maintain clinical information in health management systems, support service authorization for transfers/discharges, and provide utilization education while improving the authorization review process.
Location: California
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Perform medical necessity and clinical reviews of prior authorization requests to determine medical appropriateness of care.
  • •Coordinate with healthcare providers and the authorization team to ensure timely review of services and requests.
  • •Assess member medical necessity of care in coordination with healthcare providers and interdepartmental teams, escalating to Medical Directors as appropriate.
  • •Support service authorization for transfer or discharge plans to help ensure timely discharge between levels of care and facilities.
  • •Collect, document, and maintain member clinical information in health management systems; provide education on utilization processes and suggest improvements to the authorization review process.

Pay and Benefits

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

Key Requirements

  • •CA RN license required.
  • •Graduate from an accredited school of nursing or a Bachelor’s degree in nursing.
  • •2–4 years of related experience.
  • •Ability to analyze authorization requests and determine medical necessity of service.
  • •Knowledge of Medicare and Medicaid regulations and utilization management processes (preferred).
Experience:2-4 years
Education:Bachelor's in Nursing
Skills:CommunicationDocumentationAttention to detailProcess improvement
Licenses:RN licenseCA RN required
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