Senior RN Clinical Review Nurse - Prior Authorization

## About the Role As a Senior RN Clinical Review Nurse at Centene Corporation, you will play a critical role in ensuring that patients receive the care they need in a timely and efficient manner. Your expertise will be applied to reviewing prior authorization requests, assessing medical necessity, and collaborating with healthcare providers to promote high-quality patient outcomes. This position requires a strong understanding of clinical guidelines, regulatory requirements, and the ability to analyze complex medical information.

The Senior RN Clinical Review Nurse role is part of Centene's Medical Management/Health Services team, which is dedicated to delivering innovative solutions that improve healthcare outcomes for millions of patients. As a member of this team, you will have the opportunity to work with a diverse group of professionals who share your passion for delivering exceptional patient care.

In this role, you will be responsible for managing prior authorization requests, conducting medical necessity reviews, and collaborating with healthcare providers to ensure that patients receive the care they need. Your expertise will be applied to driving quality and cost-effective care, and you will have the opportunity to develop in-depth knowledge of the prior authorization process.

## What You Will Do - Review prior authorization requests to determine medical necessity of service and appropriate level of care - Conduct medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care - Collaborate with healthcare providers and authorization teams to ensure timely review of services and/or requests - 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 and review all member's clinical information in health management systems to ensure compliance with regulatory guidelines - 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 - Partner with interdepartmental teams on projects within utilization management as part of the clinical review team

## What We Are Looking For - Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing - 4-6 years of related experience - Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service - Strong knowledge of Medicare and Medicaid regulations - Strong knowledge of utilization management processes - LPN - Licensed Practical Nurse - State Licensure required (NY RN Licensure required for this position) - Ability to work in a fast-paced environment and prioritize multiple tasks - Excellent communication and interpersonal skills - Ability to work collaboratively with cross-functional teams

## Nice to Have - Experience with electronic health records and health management systems - Certification in utilization review or case management - Experience with prior authorization and medical necessity reviews - Knowledge of regulatory requirements and accreditation standards

## Benefits and Perks - Competitive pay and benefits package - Comprehensive health insurance - 401K and stock purchase plans - Tuition reimbursement - Paid time off plus holidays - Flexible approach to work with remote, hybrid, field, or office work schedules - Opportunities for professional development and growth - Collaborative and dynamic work environment - Recognition and rewards for outstanding performance

- Tip: Make sure to highlight your experience with prior authorization and medical necessity reviews in your resume and cover letter.

• Tip: Be prepared to discuss your knowledge of regulatory requirements and accreditation standards during the interview process.
• Tip: Showcase your ability to work collaboratively with cross-functional teams and communicate effectively with healthcare providers.
• Tip: Consider obtaining certification in utilization review or case management to demonstrate your expertise and commitment to the field.
• Tip: Be prepared to discuss your experience with electronic health records and health management systems, and how you have applied this knowledge in previous roles.
• Tip: Research the company culture and values, and be prepared to discuss how your skills and experience align with these.
• Tip: Don't be afraid to ask questions during the interview process, such as what a typical day looks like in the role, or what opportunities there are for professional development and growth.