Job Description:
Job Title: Clinical Review Nurse - Concurrent Review
Location: Remote for candidates residing in AZ, CO, & LA
Duration: 3 months (Possible Extension & Conversion)
Shift Schedule: 12PM- 9PM CST (Must be able to work a Saturday or Sunday each week.)
Position Summary:
Seeking a Clinical Review Nurse Concurrent Review to join our Utilization Management team. The nurse will be responsible for performing concurrent reviews of members to evaluate the appropriateness of care and level of service, monitor overall member health status, and support discharge planning in accordance with internal policies and clinical guidelines.
This position will also involve composing and processing denial letters and working collaboratively with providers and internal teams to ensure quality care delivery aligned with Centene's standards.
Key Responsibilities:
Perform concurrent reviews to assess member health status, validate medical necessity, and determine appropriate level of care.
Evaluate quality and continuity of care by assessing acuity, resource use, and discharge plans.
Collaborate with Medical Affairs/Medical Directors to discuss and confirm care determinations.
Document findings, discharge planning details, and actions taken in the health management system.
Generate and send denial letters to members and providers (expected average: 2.6 letters per hour).
Educate providers on utilization processes and care expectations.
Offer feedback to leadership on care appropriateness and clinical guideline adherence.
Coordinate with care management for referrals and transitions between care levels.
Ensure compliance with Centene's policies and standards in all review processes.
Required Qualifications:
Graduate of an Accredited School of Nursing or Bachelor's Degree in Nursing.
Compact State Nursing License (RN or LPN).
2 4 years of relevant nursing or utilization management experience.
Strong computer literacy and electronic documentation skills.
Proficient in medical terminology and clinical assessments.
Preferred Qualifications:
Prior experience writing clinical denial letters.
Familiarity with Medicare and Medicaid regulations.
Knowledge of utilization management processes and review systems.
Performance Expectations:
Ability to consistently meet daily productivity metrics (e.g., 2.6 letters/hour).
Demonstrate clear and accurate clinical documentation.
Timely completion of tasks with minimal supervision.
High attention to detail and quality of work.
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