Clinical Review Nurse – Concurrent Review

🔥 1 minute ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines • Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member • Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care • Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member • Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered • Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines • Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings • Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members • Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines • Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities • Collaborates with care management on referral of members as appropriate • Performs other duties as assigned • Complies with all policies and standards

🎯 Requirements

• Prefer a compact RN licensure with a minimum of 2 years acute care clinical experience • Must be able to work eastern time zone hours either Tuesday - Saturday or Sunday - Thursday with rotational holidays (approximately 3/year) • Knowledge of Utilization Management and Medicare and Medicaid regulations preferred • Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience • 2+ years of acute care experience required • 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 - Licensed Practical Nurse - State Licensure required • RN - Registered Nurse - State Licensure and/or Compact State Licensure For State of Nevada required • No travel

🏖️ Benefits

• competitive pay • 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 • Benefits may be subject to program eligibility