Clinical Review Nurse - Concurrent Review
location_onCity Common Plaza, Central Business District, Orlando, Orange County, Florida, 32801, United States
Job Description
About the Role
Be among the first to join our Medical Management/Health Services team as a Clinical Review Nurse. In this role, you could be the one who changes everything for our 28 million members by ensuring they receive appropriate, high-quality care. As a clinical professional, you will play a pivotal part in evaluating medical necessity and contributing to discharge planning, directly impacting the health outcomes of our diverse membership.
Centene is a diversified, national organization that offers competitive benefits and a fresh perspective on workplace flexibility. We are committed to providing a supportive environment where clinical professionals can thrive while delivering exceptional service to our members.
Your Impact
As a Clinical Review Nurse, you will perform concurrent reviews to determine the member's overall health, evaluate the type of care being delivered, and assess medical necessity. You will assist in evaluating inpatient services to validate the necessity and setting of care, ensuring that members receive the right level of treatment in the appropriate environment.
Your work will involve collaborating closely with healthcare providers, Medical Affairs, and Medical Directors to discuss member care, approve medical determinations, and provide recommendations based on your review findings. You will also play a key role in education, providing providers with insights into utilization processes to ensure high-quality, appropriate care is delivered.
Additionally, you will offer feedback to leadership on opportunities to improve the appropriate level of care and medical necessity. By reviewing member transfer or discharge plans, you will help ensure timely transitions between levels of care and facilities, while collaborating with care management on member referrals as needed.
Our Culture and Commitment
Centene is an equal opportunity employer committed to diversity and inclusion. We believe that our strength lies in our differences, and we are dedicated to fostering a workplace where all individuals feel valued and respected. 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 characteristic.
We also recognize the importance of giving everyone a fair chance. Applicants with arrest or conviction records will be considered in accordance with applicable laws, ensuring that our hiring practices are both fair and compliant with legal standards.
Join Us
If you are a Registered Nurse with a passion for clinical review and a desire to make a meaningful impact on the lives of millions, we invite you to apply. This is an opportunity to bring your expertise in utilization management and acute care to a team that values your contributions and supports your professional growth.
Work location
Work model: Remote
City Common Plaza, Central Business District, Orlando, Orange County, Florida, 32801, United States
Orlando, Florida
Key Responsibilities
- check_circlePerform concurrent reviews to determine medical necessity and appropriate level of care
- check_circleCollaborate with healthcare providers to approve medical determinations
- check_circleDocument and maintain concurrent review findings in health management systems
- check_circleProvide education to providers on utilization processes
- check_circleAssess acuity levels, resource consumption, and length of stay
- check_circleReview member transfer or discharge plans to ensure timely transitions
- check_circleEvaluate inpatient services to validate the necessity and setting of care
Requirements
- verifiedGraduation from an accredited School of Nursing or Bachelor’s degree in Nursing
- verified2-4 years of related experience
- verified2+ years of acute care experience
- verifiedRegistered Nurse (RN) license required
- verifiedLPN license required for Health Net of California
- verifiedMust be State Licensed
- verifiedInterQual and Trucare experience a plus
- verifiedUtilization management and concurrent review experience strongly preferred
- verifiedKnowledge of Medicare and Medicaid regulations and utilization management processes preferred
Benefits & Perks
Skills, education and keywords
Skills: utilization management, concurrent review, acute care, interqual, trucare, state licensure, rn license, lpn, medicare, medicaid.
Education: Bachelor’s degree in Nursing required.