Transforming the health of the communities we serve, one person at a time.
Clinical Review Nurse-Concurrent Review
Location
United States
Posted
4 days ago
Salary
$27 - $49 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Clinical Review Nurse-Concurrent Review
Centene Corporation
Role Description 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. Position Purpose: - Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. - Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. - 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. Qualifications - Requires graduation from an accredited school of nursing or a Bachelor’s degree in Nursing (BSN). - 2–4 years of related nursing experience. - A minimum of 2 years of acute care experience is 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. Requirements - LPN - Licensed Practical Nurse - State Licensure required. - NYS RN Licensure Strongly Preferred. Benefits - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - 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.
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