Clinical Review Nurse – Concurrent Review

🔥 0 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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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 to determine members’ overall health, evaluate medical necessity, assess the type and setting of care, and contribute to discharge planning • Evaluate inpatient services to validate the necessity and setting of care • Review acuity level, resource consumption, length of stay, and discharge planning to assess quality and continuity of care • Work with Medical Affairs and/or Medical Directors regarding member care • Collect, document, and maintain concurrent review findings, discharge plans, and actions taken in member medical records and health management systems • Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and review findings • Educate providers on utilization processes • Provide leadership feedback on opportunities to improve level of care and medical necessity • Review member transfer or discharge plans to support timely transitions between levels of care and facilities • Collaborate with care management on member referrals • Perform other duties as assigned and comply with policies and standards

🎯 Requirements

• Must reside in Missouri • Active Missouri RN licensure required • Graduate from an accredited school of nursing or bachelor’s degree in nursing • 2–4 years of related experience required • 2+ years of acute care experience required • Clinical background; managed care and utilization management/review experience helpful • Clinical knowledge to determine members’ overall health, treatment needs, and appropriate level of care preferred • Knowledge of Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred • RN state licensure and/or compact state licensure for Missouri Medicaid required • Ability to work Monday–Friday, 8am–5pm Central Time, with 1–2 rotational holidays per year

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • Stock purchase plans • Tuition reimbursement • Paid time off • Holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Incentives may be included in total compensation