Clinical Review Nurse – Prior Authorization

🔥 13 hours ago

🗽 New York – Remote

🗽 New York – Remote

💵 $27 - $48 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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

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

🎯 Requirements

• Active New York RN license • Ability to work Monday through Friday, 8:30 AM to 5:00 PM ET, with a one-hour lunch break • Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing • 2 to 4 years of related experience • 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 • For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license; examples include Nursing, PT and OT • Compliance with all policies and standards

🏖️ 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 • Equal opportunity employer committed to diversity