Clinical Review Nurse – Concurrent Review

🔥 0 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

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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

• Complete timely inpatient utilization reviews against medical necessity criteria, health plan policies, and applicable standards • Review clinical records, document decisions, and refer appropriate cases for medical director review • Coordinate care and support discharge planning with providers, facilities, and internal teams • Assist with quality reviews, audits, and compliance activities • Manage daily case volume while meeting quality, turnaround time, and productivity expectations • Share clinical expertise with teammates and raise recurring issues or improvement opportunities to leadership • Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care • Review acuity level, resource consumption, length of stay, and discharge planning • Collaborate with Medical Affairs, Medical Directors, and care management • Maintain concurrent review findings, discharge plans, and actions in health management systems • Approve medical determinations or provide recommendations based on requested services and review findings • Educate providers on utilization processes • Review transfer and discharge plans to support timely transitions between care levels and facilities • Perform other duties as assigned and comply with all policies and standards

🎯 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 • RN license required for Health Net of California • RN state licensure and/or Compact State Licensure required for the state of Nevada • Clinical knowledge and ability to determine overall health, treatment needs, and appropriate level of care preferred • Knowledge of Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • 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 • Equal opportunity employment and consideration under applicable law