Senior Clinical Review Nurse – Prior Authorization

🔥 0 minutes ago

🗽 New York – Remote

🗽 New York – Remote

💵 $30 - $55 / hour

⏰ Full Time

🟠 Senior

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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

• Review challenging and complex prior authorization requests to determine medical necessity and appropriate level of care • Assess authorization requests and provide recommendations to the appropriate medical team • Perform medical necessity and clinical reviews in accordance with regulatory guidelines and criteria • Collaborate with healthcare providers and authorization teams to ensure timely service reviews and authorized care • Escalate requests to Medical Directors when appropriate • Manage authorization requests related to member transfers and discharge plans • Provide feedback to improve the authorization review process • Assess medical necessity with healthcare providers, utilization management, and care management teams • Partner with interdepartmental utilization management teams on projects • Review member clinical information in health management systems for regulatory compliance • Educate providers and interdepartmental teams on utilization processes • Develop in-depth knowledge of prior authorization and train other team members • Perform other assigned duties and comply with policies and standards

🎯 Requirements

• New York State licensure as an RN, OT, or PT • Graduate from an accredited school of nursing or bachelor's degree in nursing • 4–6 years of related experience • Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity preferred • Strong knowledge of Medicare and Medicaid regulations preferred • Strong knowledge of utilization management processes preferred • For Fidelis Plan only: clinical degree as a healthcare professional with the appropriate license, such as Nursing, PT, or OT

🏖️ Benefits

• Competitive pay • Health insurance • 401K plans • Stock purchase plans • Tuition reimbursement • Paid time off • Holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Incentives may be included in total compensation