Senior Concurrent Review Nurse

Centene Corporation Baton Rouge , LA 70804

Posted 5 months ago

Position Purpose:

Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations

Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care

Conduct discharge planning

Educate providers on utilization and medical management processes

Provide clinical knowledge and act as a clinical resource to non-clinical team staff

Enter and maintain pertinent clinical information in various medical management systems

Direct care to participating network providers

Participate in utilization management committees and work on special projects related to utilization management as needed

Serve as a subject matter expert for questions or issues for other Concurrent Review Nurses and Prior Authorization Nurses

Audit case reviews to ensure compliance with utilization management policies and procedures

Assist with the development of utilization management workflows, policies, and procedures

For New Hampshire: In addition to the above bullets, home visits required.

For Arizona Complete Health, in addition to the above bullets:

Research and validate accuracy of lapsed authorization data with staff and provide reports summarizing results

Lead and facilitate multiple weekly rounds with staff, medical directors, and external contracted providers

Assist with training for new hires and continued development of existing staff

Serve as a back up to direct manager as needed

Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

Education/Experience:

Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2 years of clinical nursing experience and 3 years of utilization management experience in a managed care setting.

Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs.

RN strongly preferred.

Licenses/Certifications:

Current state's LPN/LVN or RN license.

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.



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Senior Concurrent Review Nurse

Centene Corporation