Concurrent Review Nurse - Audits

You could be the one who changes everything for our 26 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

This position is available for those residing in, and licensed in, CA only.
Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

• Direct care to participating network providers
• Conduct discharge planning
• Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care
• Participate in utilization management committees and work on special projects related to utilization management as needed
• Enter and maintain pertinent clinical information in various medical management systems
• For New Hampshire and Massachusetts - home visits required
• Educate providers on utilization and medical management processes
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff
• Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience and 1+ years of utilization management experience in a managed care setting. Acute care experience preferred. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs
Licenses/Certifications: Current CA LPN/LVN or RN license.

Pay range: $36.58 - 65.72 per hour

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. The employee may be eligible for bonuses and other forms of compensation.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.