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Senior Clinical Review Nurse – Prior Authorization
Centene CorporationCentene, a healthcare solutions provider, needs a clinical nurse to review complex prior authorizations. Determining medical necessity, coordinating care, and supporting compliant utilization management.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates advanced clinical knowledge in medical necessity assessments and authorization processes, with a strong understanding of Medicare and Medicaid regulations. Capable of collaborating effectively with healthcare providers and interdepartmental teams to enhance utilization management and ensure compliance.
Highest-signal resume keywords
New York State Licensure as RN, OT, or PTAdvanced Clinical KnowledgeUtilization Management ProcessesMedicare and Medicaid RegulationsPrior Authorization Expertise
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity AssessmentClinical ReviewAuthorization Request ManagementRegulatory Compliance ReviewFeedback Provision for Process Improvement
Soft Skills
CollaborationCommunicationTraining and Education
Tools & Technologies
Health Management Systems
Certifications & Qualifications
RN LicensureOT LicensurePT Licensure
Industry Keywords
Prior AuthorizationUtilization ManagementHealthcare ProvidersInterdepartmental CollaborationClinical Information Review
About the role
Key responsibilities & impact- Review challenging and complex prior authorization requests to determine medical necessity and appropriate level of care
- Assess authorization requests and provide recommendations to the appropriate medical team
- Perform medical necessity and clinical reviews in accordance with regulatory guidelines and criteria
- Collaborate with healthcare providers and authorization teams to ensure timely service reviews and authorized care
- Escalate requests to Medical Directors when appropriate
- Manage authorization requests related to member transfers and discharge plans
- Provide feedback to improve the authorization review process
- Assess medical necessity with healthcare providers, utilization management, and care management teams
- Partner with interdepartmental utilization management teams on projects
- Review member clinical information in health management systems for regulatory compliance
- Educate providers and interdepartmental teams on utilization processes
- Develop in-depth knowledge of prior authorization and train other team members
- Perform other assigned duties and comply with policies and standards
Requirements
What you’ll need- New York State licensure as an RN, OT, or PT
- 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 preferred
- Strong knowledge of Medicare and Medicaid regulations preferred
- Strong knowledge of utilization management processes preferred
- For Fidelis Plan only: clinical degree as a healthcare professional with the appropriate license, such as Nursing, PT, or OT
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K plans
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Incentives may be included in total compensation