Clinical Review Nurse - Concurrent Review
Remote-MI, United States
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.
- Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
- Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
- Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
- Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
- Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
- Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
- Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
- Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
- Collaborates with care management on referral of members as appropriate
- Performs other duties as assigned
- Complies with all policies and standards
This is a remote position, available to candidates located in Michigan. Ideal candidate will have a Michigan, RN license.
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
- LPN - Licensed Practical Nurse - State Licensure required
- RN preferred.
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. Total compensation may also include additional forms of incentives.
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.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Job Profile
Remote only for candidates in Michigan
Benefits/Perks401(k) Competitive benefits Competitive pay Comprehensive benefits package Flexible approach Flexible work schedules Health insurance Holidays Paid Time Off Stock purchase Stock purchase plans Tuition reimbursement Workplace flexibility
Tasks- Clinical review
- Collaborate with healthcare providers
- Concurrent review
- Document findings
- Evaluate medical necessity
- Perform concurrent reviews
- Provide education to providers
Acute care Care management Clinical knowledge Clinical Review Discharge planning Education Healthcare Health Insurance Health management systems Health Services Insurance Leadership Medicaid Medicaid regulations Medical management Medical necessity Medical Records Medicare Nursing Planning RN Utilization management
Experience2-4 years
EducationBachelor’s Degree in Nursing Degree in nursing Graduate from an accredited school of nursing Healthcare LPN Nursing Nursing Diploma RN
CertificationsLicensed practical nurse LPN LPN license RN RN License
TimezonesAmerica/Anchorage America/Chicago America/Denver America/Los_Angeles America/New_York Pacific/Honolulu UTC-10 UTC-5 UTC-6 UTC-7 UTC-8 UTC-9