Senior RN Clinical Review Nurse - Prior Authorization

This position is for a clinical professional supporting the Medical Management/Health Services team at Centene, focusing on prior authorization reviews and healthcare provider collaboration, primarily for the Fidelis state plan in New York.

Location: New York, NY

Salary: $30.58 - $55.09 per hour

Responsibilities

• Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• Collaborate with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
• Escalate prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
• Manage service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Provide feedback on opportunities to improve the authorization review process for members
• Manage as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care
• Partner with interdepartmental teams on projects within utilization management as part of the clinical review team
• Manage and review all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
• Provide education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
• Develop in-depth knowledge of the prior authorization process and act as a trainer to other team members
• Perform other duties as assigned
• Comply with all policies and standards

Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 4 – 6 years of related experience

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work arrangements including remote, hybrid, field or office work schedules

Additional Information

• This position supports our Fidelis state plan and requires NY RN Licensure