Clinical Review Nurse (remote)

We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.

You could be the one who changes everything for our 28 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. Work Location This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours. Schedule This position follows a Monday–Friday schedule from 830 AM to 500 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours. Position Purpose Analyzes all 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. 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 Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards