Clinical Review Nurse (remote)
Fulton Montgomery Regional Chamber of Commerce · Latham, NY
- On site
- Part-time
- $75,000 / year
- Latham, NY
Job highlights
- Remote Clinical Review Nurse role.
- Requires active NYS RN license.
- Analyze prior authorization requests.
- Determine medical necessity of care.
- Monday-Friday, 8:30 AM - 5:00 PM ET.
About the role
About The Job
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.Work Location
This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours.Licensure Requirement
Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration.Schedule
This position follows a Monday–Friday schedule from 830 AM to 500 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours.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 requiredThis position is aligned to support Fidelis Care. NYS RN 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.Key skills/competency
- Clinical Review Nurse
- Registered Nurse
- Prior Authorization
- Medical Necessity
- Utilization Management
- NYS RN Licensure
- Healthcare
- Clinical Review
- Patient Care
- Medical Management
Skills & topics
- Clinical Review Nurse
- Registered Nurse
- Utilization Management
- Prior Authorization
- Medical Necessity
- Healthcare
- Remote Work
- NYS RN Licensure
- Clinical Review
- Health Services
How to get hired
- Tailor your resume: Highlight your NYS RN licensure and clinical review experience.
- Emphasize skills: Showcase knowledge of utilization management and medical necessity determination.
- Address requirements: Clearly state your availability for Eastern Time hours and remote work.
- Prepare for interviews: Be ready to discuss your experience with prior authorization requests.
Technical preparation
Review nursing and clinical guidelines.,Study utilization management processes.,Familiarize with Medicare/Medicaid regulations.,Practice analyzing clinical data.
Behavioral questions
Describe handling complex clinical reviews.,How do you ensure timely patient care?,Explain your communication with healthcare providers.,How do you manage multiple authorization requests?
Frequently asked questions
- What is the work arrangement for the Clinical Review Nurse position at Centene?
- The Clinical Review Nurse position at Centene is a fully remote role. This means you can work from home, but must be able to work Eastern Time (ET/EST) hours and hold an active New York State Registered Nurse (RN) licensure.
- What specific licensure is required for the Clinical Review Nurse job?
- An active and unrestricted New York State Registered Nurse (RN) licensure is strictly required for this Clinical Review Nurse position. While LPN licensure is mentioned, the primary requirement for this role is RN licensure in NYS.
- Can I apply for the Clinical Review Nurse role if I don't have New York State RN licensure?
- Unfortunately, no. An active and unrestricted New York State Registered Nurse (RN) licensure is a mandatory requirement for this Clinical Review Nurse position. Without it, your application cannot be considered.
- What are the typical working hours for this remote Clinical Review Nurse position?
- The Clinical Review Nurse role operates on a Monday–Friday schedule, from 8:30 AM to 5:00 PM Eastern Time (ET/EST). This includes a one-hour assigned lunch break. Candidates must be available to work during these core hours.
- What will be my main responsibilities as a Clinical Review Nurse at Centene?
- As a Clinical Review Nurse, your primary responsibility will be to analyze prior authorization requests to determine medical necessity, appropriate level of care, and compliance with standards and benefits. You will also provide recommendations, coordinate with providers, and maintain member clinical information.
- What is the preferred experience for the Clinical Review Nurse role?
- While a Bachelor's degree in Nursing and 2-4 years of related experience are required, clinical knowledge and experience analyzing authorization requests to determine medical necessity are preferred. Familiarity with Medicare, Medicaid regulations, and utilization management processes is also beneficial.
- What benefits does Centene offer to its employees?
- Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, and paid time off plus holidays. They also emphasize a flexible approach to work schedules.