Clinical Review Nurse – Concurrent Review

🔥 1 minute ago

🏄 California – Remote

🏄 California – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Perform concurrent reviews of inpatient medical admissions for pediatric and adult members within the LA Medicaid line of business • Determine members’ overall health, appropriate care, medical necessity, and level of care • Review acuity level, resource consumption, length of stay, and discharge planning • Work with Medical Affairs and/or Medical Directors regarding member care • Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems • Work with healthcare providers to approve medical determinations or provide recommendations • Educate providers on utilization processes • Provide leadership feedback on opportunities to improve level of care and medical necessity • Review transfer and discharge plans to support timely transitions between levels of care and facilities • Collaborate with care management on member referrals • Comply with policies and standards and perform other assigned duties

🎯 Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing • 2–4 years of related experience • 2+ years of acute care experience required • LPN state licensure required, or RN state licensure and/or Compact State • Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred • Knowledge of Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred • Standard hours of 8am–5pm CST with weekend and holiday rotation • Ability to conduct clinical reviews of inpatient medical admissions for pediatric and adult members • Knowledge of utilization management policies and guidelines

🏖️ Benefits

• Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation