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About the Role
Analyzes prior authorization requests to determine medical necessity and appropriate level of care, ensuring quality and cost-effectiveness. Provides recommendations to the medical team to promote optimal medical care.
Responsibilities
- 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.
- Coordinates with healthcare providers and interdepartmental teams to assess medical necessity of care.
- Escalates prior authorization requests to Medical Directors as appropriate.
- Assists with service authorization requests for member transfers or discharge plans.
- Collects, documents, and maintains member clinical information in health management systems.
- Assists with providing education to providers and interdepartmental teams on utilization processes.
- Provides feedback on opportunities to improve the authorization review process.
- Performs other duties as assigned.
- Complies with all policies and standards.
Requirements
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
- 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.
Skills
- Medical necessity determination
- Clinical review
- Authorization request analysis
- Healthcare provider coordination
- Interdepartmental coordination
- Medical Director escalation
- Discharge planning
- Clinical information documentation
- Utilization process education
- Process improvement feedback
Location
- Remote
- Hybrid
- Field
- Office
Work Type
- Remote
- Hybrid
- Field
- Office
- Full-time
Experience Level
- 2-4 years of related experience
Education Level
- Graduate from an Accredited School of Nursing
- Bachelor’s degree in Nursing
- LPN - Licensed Practical Nurse - State Licensure
- RN license
- Clinical degree as a healthcare professional
Salary/Compensations
- $27.02 - $48.55 per hour
Benefits
- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Holidays
About the Company
- Centene connects people to the care they need to live healthier lives.
- The work done at Centene makes a real impact every day.
- You’ll take on meaningful challenges that directly support individuals, families, and communities.
- Build your skills while making healthcare more accessible and effective.
- It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Equal Opportunity
- 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.