Clinical Review Nurse - Concurrent Review

📋 Description

• • As a Clinical Review Nurse specializing in Concurrent Review at Centene Corporation, you will play a pivotal role in ensuring our 28 million members receive the appropriate and necessary care. This position is integral to our Medical Management/Health Services team, where your clinical expertise will directly impact patient outcomes and resource utilization.
• • Your primary responsibility will be to conduct concurrent reviews, meticulously evaluating the ongoing care of hospitalized members. This involves assessing the member's overall health status, the type of care currently being delivered, and critically evaluating the medical necessity of the treatment plan and the healthcare setting.
• • You will be tasked with reviewing hospital requests for payment approval, making informed decisions on authorizing a defined number of inpatient days based on established clinical policies and guidelines.
• • A key aspect of your role will be to collaborate closely with healthcare providers, including physicians and hospital staff, to discuss member care, validate treatment plans, and ensure alignment with Centene's care standards.
• • You will work with Medical Affairs and/or Medical Directors when complex cases or significant deviations from standard care pathways arise, contributing your clinical insights to facilitate optimal decision-making.
• • Accurate and thorough documentation is paramount. You will be responsible for collecting, documenting, and maintaining detailed records of all concurrent review findings, discharge plans, and actions taken within our health management systems, adhering strictly to utilization management policies and guidelines.
• • Beyond authorization, you will actively contribute to discharge planning, ensuring a smooth and timely transition for members between different levels of care and facilities. This includes reviewing transfer and discharge plans to confirm they meet the member's ongoing needs.
• • You will also play an educational role, providing valuable feedback and guidance to healthcare providers on utilization management processes. This ensures that high-quality, appropriate care is delivered consistently and efficiently.
• • Your insights will be crucial in identifying opportunities for improvement. You will provide feedback to leadership regarding potential enhancements to the appropriateness of care levels and the validation of medical necessity, based on your direct clinical observations and adherence to policies.
• • Collaboration extends to our care management teams. You will work with care managers to identify and facilitate referrals for members who may benefit from additional support or specialized care management programs.
• • This role requires a proactive approach to patient care, focusing on both the immediate needs of the member during their hospital stay and their long-term health trajectory.
• • You will be expected to stay current with evolving clinical practices, healthcare regulations, and Centene's internal policies to ensure the highest standard of care is maintained.
• • The position operates on a Monday to Friday schedule, typically from 8 am to 5 pm Pacific Time, offering a predictable work-life balance.
• • You will manage a daily volume of approximately 17–20 concurrent reviews, requiring efficient time management and strong organizational skills.
• • Comprehensive training will be provided over 4-5 weeks, followed by a 12-week ramp-up period where you will gradually increase your case load from 0 to 20 cases, with dedicated preceptor support to ensure a successful transition into the role.
• • This is a remote position based in California, offering the flexibility to work from home while serving our diverse membership.