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. Centene is hiring a Remote Clinical Review Nurse – Prior Authorization to support our Duals team. The ideal candidate will have experience reviewing outpatient services, with a background in one or more of the following areas: - Imaging services - Durable Medical Equipment (DME) - Home Health Care - Elective inpatient services This role is responsible for conducting clinical reviews for prior authorization requests in accordance with medical necessity guidelines, regulatory requirements, and company policies. This is a remote position with standard business hours, Monday through Friday, 8:00 AM–5:00 PM any time zone with potential for weekend, holiday, and on-call coverage or Sunday through Thursday 9am-6pm. 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 Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 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. License/Certification: - LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. 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

• Provides timely medical review of service requests • Interacts with physicians and health plan members as needed • Reviews clinical determinations that cannot be made initially • Provides clinical rationale for appeals and ensures proper documentation

• Perform medical review and assessment of Individual Case Safety Reports (ICSRs), including evaluation of seriousness, causality, expectedness, and clinical relevance. • Conduct signal detection and signal evaluation using safety databases and statistical tools such as disproportionality analysis. • Analyze aggregate safety data from clinical trials, post-marketing surveillance, and scientific literature to identify emerging safety trends. • Support the preparation and review of Periodic Safety Update Reports (PSURs), PBRERs, DSURs, and Risk Management Plans (RMPs). • Participate in signal management activities, including signal validation, prioritization, documentation, and escalation. • Provide medical input for benefit-risk assessments of marketed and investigational products. • Monitor and interpret safety trends and emerging risks from pharmacovigilance databases and external sources. • Collaborate with clinical, regulatory, epidemiology, and safety teams to evaluate signals and develop risk mitigation strategies. • Ensure compliance with global pharmacovigilance regulations (FDA, EMA, ICH E2E, E2D, GVP Modules). • Contribute to SOP development, safety governance meetings, and safety review committees. • Support responses to health authority queries and prepare for safety audits and inspections.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Dane Street is expanding our physician panel! This is a telework opportunity for supplemental income for physicians providing a caseload customized to your schedule. Our physician panel is comprised of independent contract reviewers (1099) compensated on a per-case basis. As a Physician Reviewer/Advisor for Disability Peer Review, you will utilize clinical expertise to review medical records provided and return an independent, professional opinion on the claimant’s functionality and restrictions or limitations as it relates to an application for disability benefits or the current status of disability. Determinations are based on the clinical evidence within the medical records provided. - On a contract basis, as individual schedule permits, accepts cases, reviews all medical records, and addresses each question posed utilizing client-specific criteria or other nationally recognized evidence-based criteria, and opines on disability status. - Ensures a clear rationale for the determination that is concise and contains adequate supporting documentation to substantiate the decision. - Identifies and employs current criteria and resources, such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions. - Provides a report and copies of any criteria utilized within the review promptly. - Returns cases on or before the due date and time specified. - Completes peer-to-peer calls/call attempts as required based on client-specific protocol with the goal of obtaining information not included in medical records as well as any necessary clarification. - Performs other duties as assigned, including addressing any necessary clarification, providing addendum as required (with additional compensation), identifying and responding to potential quality assurance issues, complaints, and regulatory issues. Qualifications - US Board certification required, active practice preferred. Benefits - Robust opportunity for supplemental income. - Schedule flexibility and predictable work hours - You choose services and case types, dictate volume, and conduct exams and reviews based on your schedule availability. - No doctor/patient relationship is established, and no treatment is provided. These are advisory-only opinions. - Enhanced industry expertise, strengthening your medical practice with medical necessity and utilization review/management expertise. - Expanded credentials as an expert in Independent Medical Exams and physician advisor services. - Fully prepped cases, streamlined case flow, transcription services at no cost, and a user-friendly work portal. - Dane Street supports all referral processes, scheduling, preps cases extensively, prepares all medical records, provides transcription services as applicable, facilitates all client communications, and ensures the quality and timeliness of all reports and report delivery.