Centene Corp

Senior Clinical Review Nurse - Prior Authorization

Centene Corp$63K — $114K *
US-AnywhereRemote in New York, US
Healthcare
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • New York State Licensure as RN, OT or PT required
  • Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
  • 4-6 years of related experience required
  • Advanced clinical knowledge for analyzing authorization requests preferred
  • Strong knowledge of Medicare and Medicaid regulations preferred
  • Familiarity with utilization management processes preferred

Responsibilities

  • Perform medical necessity reviews to assess clinical appropriateness of services
  • Collaborate with healthcare providers for timely service reviews
  • Escalate complex authorization requests to Medical Directors
  • Manage service authorization for member transfers and discharges
  • Provide feedback to enhance the authorization review process
  • Engage with teams to assess medical necessity of care
  • Educate providers on utilization processes for quality care
  • Develop in-depth knowledge of prior authorization to train team members

Benefits

  • Competitive pay
  • Health insurance
  • 401K and stock purchase plans
  • Tuition reimbursement
  • Paid time off plus holidays
  • Flexible work schedules (remote, hybrid, field, or office)
Full Job Description
This position requires NY State Licensure as a RN, OT or PT

Position Purpose: Routinely reviews more challenging prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
  • Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
  • Collaborates with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
  • Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
  • Manages service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
  • Provides feedback on opportunities to improve the authorization review process for members
  • Manages as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care
  • Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
  • Manages and reviews all member's clinical information in health management systems to ensure compliance with regulatory guidelines
  • Provides education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
  • Develops in-depth knowledge of the prior authorization process and acts as a trainer to other team members
  • Performs other duties as assigned
  • Complies with all policies and standards


Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 4 - 6 years of related experience.

Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
Strong knowledge of Medicare and Medicaid regulations preferred.
Strong knowledge of utilization management processes preferred.

License/Certification:
  • For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT. required


Pay Range: $30.58 - $55.09 per hour

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

About Centene Corp

Centene Corporation is a managed healthcare enterprise at the forefront of innovation and growth for government-sponsored and commercial healthcare, providing access to fully integrated, high-quality, and cost-effective services that help people lead healthier lives. The company’s local approach addresses the needs of under-insured and uninsured individuals who often lack the resources required to sustain optimal health and wellness. Centene began as a single health plan in Milwaukee, Wisconsin in 1984. After an initial period of growth, Michael Neidorff joined as President and Chief Executive Officer (CEO) in 1996, moving Centene’s headquarters to St. Louis, Missouri, where it still resides today. In the decades since its humble beginnings, Centene has transformed into a publicly-traded Fortune 500 company serving communities across the United States. In fact, Centene provides coverage in all 50 U.S. states. More than 26 million Americans rely on Centene to access a wide range of insurance solutions, including Medicaid, Medicare, TRICARE, correctional, and behavioral health services. Centene prioritizes the development of technology that addresses systemic conditions impacting the whole health needs of underserved populations. As technology plays an increasingly critical role in diagnosing, managing, and treating disease, Centene understands that it enables better health outcomes for members, lessening the burden for providers, and allowing more automation and efficiency for business operations. As a steward of a significant set of data and insights, Centene leverages this data to not only shape but lead the digital transformation of healthcare and improve the patient-provider experience. Centene’s current CEO, Sarah London, and her team are leading the charge in this new age. Sarah London worked within Centene’s Technology Innovation and Modernization division, spearheading the company’s enterprise-wide technology strategy. Now leading Centene, her focus is on building the next generation of products and services and establishing Centene’s long-term growth and value creation. Although Centene has grown into the No. 1 insurer in the U.S. Health Insurance Marketplace, it has never lost its focus on the individual or its passion for community health. Remaining connected to the individuals and families that need care most is central to Centene’s commitment to shaping a better world of healthcare for the communities it serves. Centene also remains connected to the needs of its employees, who make Centene what it is. Through its commitment to diversity, equity, and inclusion practices, Centene promotes a safe and inviting environment above all. Because of Centene’s commitment to excellence and progression in the healthcare industry, it has been recognized as a Top Organization for Diversity by Modern Healthcare magazine, a Leading Disability Employer by the National Organization on Disability, a Best Place to Work for LGBTQ Equality by The Human Rights Campaign Foundation, and a global leader by Bloomberg’s Gender-Equality Index, among many other recognitions. Centene was also named a Top 50 Company for Diversity by DiversityInc and a Top Veteran-Friendly Company by U.S. Veterans Magazine. It has also been listed on FORTUNE® magazine's list of the World's Most Admired Companies for several consecutive years.

Centene Corp Careers

Join the dynamic team at Centene Corp, a leader in the healthcare industry, where your career growth and development are prioritized. At Centene Corp, we offer a range of job opportunities that allow you to make a significant impact on our community and beyond.

Explore a World of Opportunities

Discover the diverse career paths available at Centene Corp, from healthcare services to innovative program development. Our job opportunities span various professional fields, offering positions that cater to your unique skills and ambitions. Whether you're looking for an entry-level role or a senior leadership position, Centene Corp is committed to hiring top talent and fostering a culture of excellence.

Innovation and Leadership at Centene Corp

At Centene Corp, innovation and leadership go hand in hand. We empower our team members to lead with confidence and creativity, driving the company forward through strategic innovation and robust leadership. Our leadership programs are designed to cultivate your skills, helping you to thrive as a professional and make meaningful contributions to our company and the communities we serve.

Internships and Early Career Programs

Kickstart your career with Centene Corp through our internship and early career programs. These opportunities provide hands-on experience and a glimpse into the dynamic world of healthcare management. Internships at Centene Corp are a stepping stone to full-time employment, offering invaluable networking opportunities, mentorship, and the chance to develop your resume and interview skills in a real-world setting.

Commitment to Diversity and Inclusive Culture

Centene Corp is dedicated to maintaining a diverse and inclusive work environment. We believe that diversity fuels innovation and enhances our team's performance. Our diversity training ensures that all team members appreciate and leverage the broad range of experiences and perspectives that each individual brings to the company.

Benefits and Employee Growth

We value our employees' well-being and career aspirations. Centene Corp offers competitive benefits, including health insurance, retirement plans, and professional development programs. Our commitment to your growth is reflected in our continuous learning initiatives and performance management processes that help you achieve your career goals.

Join Our Team

Are you ready to advance your career at Centene Corp? Explore our current job openings and find the position that best matches your skills and interests. We are looking for passionate, curious, and solution-driven team players who are ready to make a difference.

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SEARCH CENTENE JOBS

Centene Corp is not just a company—it's a place where you can shape your future and impact the lives of millions. Join us in our mission to transform the health of the community, one person at a time.
Learn more about Centene Corp
Size
72,500 employees
Market Cap
$46.5 billion
Industry
Net Income
$1.8 billion
Founded
1984
5 Year Trend
+25.4%
Revenue
$111.1 billion
NASDAQ

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