Lead Clinical Review Nurse - Concurrent Review (Centene)

Job Description

You 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.
 

Position Purpose: Oversees all 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. Assesses the most complex inpatient services and provides guidance to validate the necessity and setting of care being delivered to the member.

• Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
• Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
• Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences
• Manages 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
• Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
• Provides education to providers on utilization processes to ensure high quality appropriate care to members
• Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
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• Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
• Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered to member, and approving treatment needs including discharge planning
• Provides guidance and expert knowledge, as appropriate, to utilization management team to address issues and validate the necessity and setting of care being delivered to the member
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
• Oversees member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collaborates with care management on referral of members as appropriate
• Provides subject matter expertise based on prior experience as well as training to other team members
• Manages reporting to identify trends and provides recommendations to various teams
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 5 – 7 years of related experience. 2+ years of acute care experience required.

Highly advanced clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Expert knowledge of Medicare and Medicaid regulations preferred.
Expert knowledge of utilization management processes preferred.

License/Certification:

• RN or LPN - State Licensure required/Compact licensure preferred.

Pay Range: $34.81 - $62.54 per hour

Centene 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.  Total compensation may also include additional forms of incentives.

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