Clinical Review Nurse – Prior Authorization
| Company | Centene |
|---|---|
| Location | Texas, USA, Georgia, USA, Kentucky, USA, Missouri, USA |
| Salary | $26.5 – $47.59 |
| Type | Full-Time |
| Degrees | Bachelor’s |
| Experience Level | Mid Level |
Requirements
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 2 – 4 years of related experience
- RN or LVN or LPN State Licensure required
Responsibilities
- Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care
- Performs medical necessity and clinical reviews of authorization requests
- Works with healthcare providers and authorization team to ensure timely review of services
- Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care
- Escalates prior authorization requests to Medical Directors as appropriate
- Assists with service authorization requests for a member’s transfer or discharge plans
- Collects, documents, and maintains all member’s clinical information in health management systems
- Assists with providing education to providers and/or interdepartmental teams on utilization processes
- Provides feedback on opportunities to improve the authorization review process
- Performs other duties as assigned
- Complies with all policies and standards
Preferred Qualifications
- 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