Senior RN 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. ***This position supports our Fidelis state plan and requires NY RN Licensure*** 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