Clinical Review Nurse - Prior Authorization (RN)

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.

Beneficios

including a fresh perspective on workplace flexibility. *CA RN required.* Position is remote

Will work PST 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.

Requisitos

, 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 criteriaWorks with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized careCoordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of memberEscalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of careAssists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilitiesCollects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelinesAssists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to membersProvides feedback on opportunities to improve the authorization review process for membersPerforms other duties as assignedComplies with all policies and standardsEducation/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years o.