Clinical Review Nurse – Concurrent Review

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – 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, including determining members’ overall health, reviewing the type of care delivered, evaluating medical necessity, and contributing to discharge planning • Evaluate inpatient services to validate the necessity and setting of care delivered to members • Determine appropriate care and level of care based on members’ overall health • Review quality and continuity of care, acuity level, resource consumption, length of stay, and discharge planning • Collaborate with Medical Affairs and/or Medical Directors regarding member care • Collect, document, and maintain concurrent review findings, discharge plans, and actions taken in 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 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 required • Texas RN or Compact License required • LPN state licensure required • RN state licensure and/or Compact State Licensure • 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 • ICU or ER experience preferred • Monday–Friday 8AM to 5PM CST and 1 weekend per month required

🏖️ 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 • Competitive pay • Additional forms of incentives may be included in total compensation