Clinical Review Nurse – Concurrent Review

🔥 1 minute ago

🐊 Florida – Remote

🐊 Florida – 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

• Conduct inpatient concurrent reviews to assess medical necessity using InterQual criteria, corporate and state policies, and available review tools • Support New Hampshire Medicaid through the East Region Shared Services team • 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 • 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 level-of-care and medical-necessity improvement opportunities • Review transfer or discharge plans to ensure timely transitions between levels of care and facilities • Collaborate with care management on member referrals • Comply with all 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 • 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 • LPN state licensure required • RN state licensure and/or compact state licensure for the State of Nevada required • Work from 8:00 a.m. to 5:00 p.m. Eastern Time • Required weekend and holiday coverage based on team needs

🏖️ 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 • Equal opportunity employer committed to diversity