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About the Role
Analyzes prior authorization requests to determine medical necessity and appropriate level of care, ensuring compliance with national standards, contractual requirements, and member benefits. Provides recommendations to the medical team to enhance quality and cost-effectiveness of 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 the authorization team to ensure timely review of services and/or requests.
- Coordinates with healthcare providers and interdepartmental teams to assess the medical necessity of care.
- Escalates prior authorization requests to Medical Directors as appropriate.
- Assists with service authorization requests for member transfer 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
- Active New York RN license required.
- Ability to work Monday through Friday, 8:30 AM to 5:00 PM ET, with a one-hour lunch break.
- 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 collaboration
- Clinical documentation
- Utilization management education
- Process improvement feedback
Location
- Remote
Work Type
- Fully remote
- Full-time
Experience Level
- 2 to 4 years of related experience
Education Level
- Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing
- Clinical degree as a healthcare professional (for Fidelis Plan Only)
Salary/Compensations
- $27.02 - $48.55 per hour
Benefits
- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work
About the Company
- At Centene, we connect people to the care they need to live healthier lives.
- You’ll take on meaningful challenges that directly support individuals, families, and communities, building 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.