Clinical Review Nurse - Concurrent Review

Lensa is a career site that helps job seekers find great jobs in the US. We are not a staffing firm or agency. Lensa does not hire directly for these jobs, but promotes jobs on LinkedIn on behalf of its direct clients, recruitment ad agencies, and marketing partners. Lensa partners with DirectEmployers to promote this job for Centene Corporation. Clicking "Apply Now" or "Read more" on Lensa redirects you to the job board / employer site. Any information collected there is subject to their terms and privacy notice.\n\nYou 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 benefits including a fresh perspective on workplace flexibility.\n\nREMOTE : 8AM to 5PM (Monday - Friday) with rotating weekends and Holidays\n\nWeekends : Every 5th weekend, Saturday and Sunday\n\nHolidays : 1 Major Holiday and 2 Minor Holidays Required\n\nRN or LPN, with 2 years of Acute Care (Or ICU) experience required\n\nInterqual Or Previous UM, CRN Experience a Plus\n\nPosition Purpose : Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.\n

• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care\n
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member\n
• Works with Medical Affairs and / or Medical Directors as needed to discuss member care being delivered\n
• Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines\n
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings\n
• Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members\n
• Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines\n
• Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities\n
• Collaborates with care management on referral of members as appropriate\n
• Performs other duties as assigned\n
• Complies with all policies and standards\n\nEducation / Experience : Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.\n\nClinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.\n\nKnowledge of Medicare and Medicaid regulations preferred.\n\nKnowledge of utilization management processes preferred.\n\nLicense / Certification\n
• LPN - Licensed Practical Nurse - State Licensure required\n
• For Health Net of California : RN license required\n\nPay Range : $26.50 - $47.59 per hour\n\nCentene offers a comprehensive benefits package including : competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.\n\nCentene 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.\n\nQualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act\n\nIf you have questions about this posting, please contact support@lensa.com