Job Overview
Location
Remote-NY
Job Type
Full-time
Category
Other
Date Posted
June 14, 2026
Full Job Description
đź“‹ Description
- • Perform concurrent reviews to assess members' overall health, appropriateness of care, and level of service delivery in accordance with clinical policies and guidelines
- • Evaluate medical necessity of inpatient services, including type of care, setting, length of stay, and resource consumption to ensure appropriate utilization
- • Review and validate discharge plans to facilitate timely transitions between levels of care and facilities
- • Collaborate with Medical Affairs and Medical Directors to discuss complex member cases and clinical determinations
- • Communicate with healthcare providers to approve or recommend medical services based on concurrent review findings
- • Document all review findings, discharge plans, and actions taken in health management systems in compliance with utilization management standards
- • Provide education to providers on utilization management processes to promote high-quality, appropriate care for members
- • Identify opportunities to improve clinical decision-making and medical necessity determinations through feedback to leadership
- • Coordinate with care management teams to refer members when appropriate for continued support or intervention
- • Maintain strict adherence to all organizational policies, clinical guidelines, and regulatory standards
- • Work a standard fully remote schedule Monday through Friday, 8:30 a.m. to 5:00 p.m. EST, with coverage on one of two assigned holidays (the day after Thanksgiving or Christmas Eve)
- • Ensure compliance with New York State (NYS) nursing licensure requirements and all applicable state and federal regulations
- • Contribute to quality improvement initiatives by analyzing trends in care delivery and utilization patterns
- • Participate in ongoing training and policy updates to maintain current knowledge of clinical standards and utilization management practices
- • Support organizational goals by promoting efficient, evidence-based care delivery across a population of 28 million members
🎯 Requirements
- • Active New York State (NYS) RN licensure required
- • Graduation from an accredited school of nursing or Bachelor’s degree in Nursing (BSN)
- • Minimum of 2–4 years of related nursing experience, including at least 2 years of acute care experience
- • Knowledge of Medicare and Medicaid regulations preferred
- • Knowledge of utilization management processes preferred
- • Clinical knowledge to determine member health status, treatment needs, and appropriate level of care preferred
🏖️ Benefits
- • Competitive pay ranging from $27.02 to $48.55 per hour
- • Comprehensive health insurance coverage
- • 401(k) and stock purchase plans
- • Tuition reimbursement
- • Paid time off plus holidays
- • Fully remote work schedule with flexible options
Skills & Technologies
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About Centene Corporation
Centene Corporation is a publicly traded managed-care enterprise that arranges health-benefit programs for government-sponsored and privately insured individuals. Operating across all 50 U.S. states and internationally, the company focuses on under-insured and uninsured populations through Medicaid, Medicare, and Marketplace offerings. Its services include behavioral health, pharmacy benefits, vision, dental, telehealth, and in-house clinical programs. Centene partners with physicians, hospitals, and community organizations to coordinate cost-effective care, emphasizing data analytics and value-based reimbursement models. Headquartered in St. Louis, Missouri, it serves more than 25 million members, positioning itself as a leading intermediary between payers and healthcare providers.
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