Clinical Review Nurse – Prior Authorization, RN

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🏄 California – Remote

🏄 California – 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

• Analyze prior authorization requests to determine medical necessity and appropriate level of care according to national standards, contractual requirements, and member benefit coverage • Provide recommendations to the appropriate medical team to promote quality and cost-effective 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 and authorized care • 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 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

• CA RN required • RN license required for Health Net of California • Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing • 2–4 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 • Hospice experience preferred • Will work PST hours

🏖️ 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 may be included in total compensation