Job 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
Centene Corporation is a diversified healthcare enterprise that provides managed care services and insurance plans, including Medicaid and Medicare programs; it operates affiliated plans such as Health Net in California.
