Clinical Review Nurse – Prior Authorization, Hospice

🔥 0 minutes ago

🏈 Alabama, Florida, +6 more states – Remote

🏈 Alabama – Remote 🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🏖️ New Jersey – Remote 🏈 Ohio – Remote 🏰 Missouri – 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

• Analyze all prior authorization requests to determine medical necessity and appropriate level of care • Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria • Work with healthcare providers and authorization teams to ensure timely review of services and requests • Coordinate with healthcare providers and interdepartmental teams to assess members’ medical necessity of care • Escalate prior authorization requests to Medical Directors when appropriate • Assist with service authorization requests for member transfer or discharge plans • Collect, document, and maintain members’ clinical information in health management systems • Educate providers and interdepartmental teams on utilization processes • Provide feedback on opportunities to improve the authorization review process • Comply with all policies and standards • Perform other duties as assigned

🎯 Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing • 2–4 years of related experience • LPN (Licensed Practical Nurse) state licensure required • Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred • Knowledge of Medicare and Medicaid regulations preferred • Knowledge of utilization management processes preferred • Registered Nurse (RN) licensure with demonstrated experience in hospice and managed care environments preferred • Applicants must be able to work Monday through Friday, 8:00 a.m. to 5:00 p.m. in their local time zone • Weekend coverage required approximately once every six weeks, including Saturday and Sunday • Rotating holiday coverage required • Ability to work remotely from home anywhere within the United States

🏖️ 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 • Flexible scheduling during the week to accommodate weekend hours worked