Clinical Review Nurse - Concurrent Review

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.
 

100% Remote but must reside in Texas for occasional in-person department meetings in a Centene or Superior Health Plan Office, when needed.

Required Training and Work Schedule: Monday - Friday 8:00am to 5:00pm (CST)

Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
• 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 medically necessity based on clinical policies and guidelines
• Reviews member’s transfer or discharge plans to ensure a timely discharge 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 Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience AND 2+ years of acute care experience required.

License/Certification:

• RN - Registered Nurse -State Licensure and/or Compact State Licensure required
• LPN - Licensed Practical Nurse - State Licensure required
• For Health Net of California: RN license required

Preferred Experience:

• Clinical Registered Nurse with direct patient care experience in Acute Care – Trauma, Critical Care, ICU, ER, Urgent Care, Surgery, Military, LTC, SNF, Triage Nursing, Med/Surg, Internal Medicine, Oncology, Neuro, Ortho, PACU, Cardiac, Veterans Hospitals, Public Health, Nursing Rehab

• Clinical knowledge and ability to determine overall health of member, including treatment needs and appropriate level of care

• Experience working within multiple CMS and EMR databases

• Strong multi-tasking and critical thinking skills required in this role to communicate with Medical Directors, clinical staff, members, and providers

• Computer navigation skills between multiple screens, Microsoft Office applications, and multiple databases - 90% of the role responsibilities. 

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.  Total compensation may also include additional forms of incentives.

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