Centene Corporation is seeking a dedicated Senior Clinical Review Nurse specializing in Prior Authorization. In this role, you will assess prior authorization requests to determine the medical necessity and appropriate level of care, ensuring compliance with national standards and member benefit coverage. Your expertise will guide healthcare providers and internal teams to deliver high-quality, cost-effective medical care to our members.

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Responsibilities:

• Analyze prior authorization requests to determine medical necessity and appropriate level of care in accordance with national standards and member benefit coverage.
• Collaborate with healthcare providers and authorization teams to ensure timely review of services, facilitating authorized care for members.
• Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of member care.
• Escalate prior authorization requests to Medical Directors as appropriate to determine the appropriateness of care.
• Assist with service authorization requests for member transfers or discharge plans to ensure timely transitions between levels of care and facilities.
• Collect, document, and maintain all member clinical information in health management systems to ensure compliance with regulatory guidelines.
• Provide education to providers and interdepartmental teams on utilization processes to promote high-quality and cost-effective medical care.
• Offer feedback on opportunities to improve the authorization review process for members.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements:

• Graduate from an accredited School of Nursing or a Bachelor’s degree in Nursing.
• 4–6 years of related experience.
• Advanced clinical knowledge and ability to analyze authorization requests to determine the medical necessity of services.
• Strong knowledge of Medicare and Medicaid regulations.
• Familiarity with utilization management processes.
• Licensed Practical Nurse (LPN) - State Licensure required.

Benefits:

Centene offers a comprehensive benefits package, including:

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible work schedules with remote, hybrid, field, or office options.

Why Join Us?

At Centene, we are committed to transforming the health of our communities, one person at a time. Our team members are dedicated to providing high-quality, culturally sensitive healthcare services. We value diversity and offer opportunities for professional growth in a supportive environment.

How to Apply:

If you are passionate about making a difference in healthcare and meet the qualifications for this role, we encourage you to apply. Please visit our careers page at Centene Careers to submit your application.

Senior Clinical Review Nurse - Prior Authorization ID-3691