Clinical Review Nurse - Concurrent Review

$26.50 - $47.59 / HOUR

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.

****NOTE: This is a fully remote role. Preference will be given to applicants (1) with an active Illinois or a compact LPN or RN licensure, (2) as well as some experience in each of the following areas: acute care, utilization management (UM), InterQual knowledge, and discharge planning knowledge.****

Additional Details:

• Department: Concurrent Review MCD

• Business Unit: Corporate

• Schedule: Mon-Fri 8am - 5pm CST with rotating weekends and holidays (required). Subject to change per business. ****

Position Purpose: Performs 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. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, 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
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews 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
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 2 – 4 years of related experience. 2+ years of acute care experience required.

Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.

Knowledge of Medicare and Medicaid regulations preferred.

Knowledge of utilization management processes preferred.

License/Certification:

LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required

Pay Range: $26.50 - $47.59 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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

Share this job

Related Jobs

Utilization Review

Full-time

Nurse Reviewer I

apartment Elevance Health location_onChicago, IL

$33.12 - $56.77 / HOUR

Anticipated End Date: 2025-12-19 Position Title: Nurse Reviewer I Job Description: Nurse Reviewer I Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: 9:30am-6:00pm local time, with rotating weekends. New Grads are encouraged to apply! The Nurse Reviewer I will be responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. How you will make an impact: Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. Notifies ordering physician or rendering service provider office of the preauthorization determination decision. Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Minimum Requirements: AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences: Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. BA/BS degree preferred. Previous utilization and/or quality management and/or call center experience preferred. Knowledge in Microsoft office. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $33.12/hr - $56.77/hr Locations: New York, New Jersey, Washington, Nevada, Maryland, Massachusetts, Illinois, District of Columbia In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws . * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Utilization Review

Full-time

Utilization Management and Review Specialist RN

apartment OSF HealthCare location_onUrbana, IL

Total Rewards "Your life - our Mission" OSF HealthCare is dedicated to provide Mission Partners with a comprehensive and market-competitive total rewards package that includes benefits, compensation, recognition and well-being offerings that focus on the whole person and engage with their current stage of life and career. Click here to learn more about benefits and the total rewards at OSF. Pay range for this position is $34.25 - $51.13/hour. Actual pay is based on years of licensure. This is a Salaried position. Overview POSITION SUMMARY: The Utilization Management and Review Specialist (UMR Specialist) evaluates patient care and activities against objective criteria in an effort to take a proactive approach in addressing appropriate admission status of each patient. In addition the UMR Specialist will identify utilization issues involving under or over utilization of services, resolves and/or refers utilization issues in accordance with established procedures. Reviews medical records to determine appropriateness and medical necessity of admission and hospital stay and use of ancillary services. Qualifications REQUIRED QUALIFICATIONS: Education: Bachelor's Degree in Nursing must be obtained within 3 years of date of hire into role. Experience: 2 years of clinical experience in an acute care or managed care setting Licensure/Certifications: Current state license as Registered Nurse Other skills/knowledge: Working knowledge of clinical EMR system PREFERRED QUALIFICATIONS: Education: Bachelor's Degree in Nursing Other Skills/Knowledge: Working knowledge of Microsoft Office applications OSF HealthCare is an Equal Opportunity Employer.

Utilization Review

Full-time

Utilization Review RN

apartment Memorial Health (IL) location_onSpringfield, IL

$32.95 - $52.73 / HOUR

Overview Shift: 12pm - 12am Performs clinical review of patient records to evaluate the utilization of acute care services. Communicates to third party payors to support the medical necessity of the hospital admission for services reimbursement. Ensures the patient care team is aware of general length of stay requirements for all patients. Facilitates physician documentation through concurrent interaction with physicians to support reimbursement and clinical severity is captured for the service rendered to patients receiving hospital care. Provides clinical knowledge and data collection for quality improvement initiatives. Optimizes reimbursement for acute care services. This is not a remote position. Responsibilities Qualifications Education: Associates Degree in Nursing. Bachelor’s Degree in Nursing preferred. Evidence of continuing professional development Licensure/Certification/Registry: Current RN licensure in the State of Illinois required Experience: Minimum of 3- 5 years of recent acute care and/or home health nursing or case management experience required. Previous utilization review experience strongly preferred. Other Knowledge/Skills/Abilities: Understanding of healthcare reimbursement mechanisms preferred. Strong oral and written communication skills. Demonstrated adaptability to changes in health care environment with proactive problem solving attitudes Understanding of the principles of performance improvement, team collaboration, and conflict resolution

Utilization Review

Part-time

RN Utilization Specialist-Utilization Review Casual Days

apartment Northwestern Medicine location_onPalos Heights, IL

Description The RN Utilization Specialist reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. The RN Utilization Specialist (RNUS) is an experienced registered professional nurse with extensive knowledge of patient care, medical treatments, hospital procedures and has expertise in hospital utilization. The RNUS through regular reviews and audits and collaboration with the clinical team, facilitates responsible decisions that promote cost effective health care services as evidenced by appropriate level of care assignment and medical necessity documentation consistent with the patient’s clinical state and intervention plan. The RNUS is a key member of the health care team and as such collaborates with clinicians, responsible for patient care plans, to provide hospital health care benefit coverage information and assist the patients in decisions based on benefits and limitations of coverage plans. The RNUS acts as a change agent to systematically drive change in utilization practices as prioritized by departmental and clinical leadership. As such, the RNUS participates in performance improvement initiatives, implements work process changes, monitors performance, and facilitates necessary changes, under the purview of the Department leadership and in collaboration with practicing clinicians, based on data trends. Responsibilities: Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure that admissions & length of stay are appropriate. Completes initial admission and thereafter continuing stay reviews for all hospitalized patients. Facilitates utilization review concurrent with decisions on hospitalization and may perform duties in the Emergency Department, pre- and post-operative, labor and delivery, external transfer, bed assignment, and / or other access points for hospitalization. Collaborates with the Payor Specialists and third-party payors to effectively communicate all relevant clinical information based on clinical indicators and the plan of care. Acts as a liaison with the clinical care team assuring compliance with managed care contracts and payor guidelines while maintaining quality of care. Partners with operational and medical leadership to identify, develop and implement utilization processes that foster the right care at the right time in the right setting. Monitors data elements inherently related to Utilization through data reporting tools. Effectively resolves utilization dilemmas and as needed uses available escalation pathways (Utilization Medical Director (s) or the Lead Utilization Specialists) to secure further information or expertise to resolve identified issues. Makes appropriate referrals to internal physician advisors and contracted third party review company per Department guidelines. May participate in interdisciplinary discharge planning rounds to facilitate communication with the care team on documentation and orders necessary to assign accurate medical necessity, level of care, and communication with the payor. Interfaces with patients as appropriate to provide education on level of care Increases stakeholder understanding of best practices in utilization and internal performance against benchmarks, through a variety of educational forums. Develops, coordinates, presents, and participates in service-line and clinician education programs. Utilizes standardized reports (metrics/dashboard) and provides updates for physicians and the interdisciplinary team members on a regular basis. Collaborates with the interdisciplinary team to promote the resolution of barriers related to utilization of services and institute changes that improve systems and promote optimal utilization practices. May assist in the reporting of financial indicators including length of stay, resource utilization, denials and appeals. Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with the healthcare team. Assists in Recovery Audit Contractor (RAC) and other audit follow up and contributes to appeals on insurance denials as requested. Additional Functions: Maintains current knowledge of federal and state laws and regulations related to utilization Actively participates on departmental and hospital committees and taskforces as assigned Complies with Northwestern Medicine policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct Facilitates review of high risk cases by the Office of General Counsel, Corporate Compliance and Integrity, Risk Management and informs appropriate members of the healthcare team as to interventions. Coordinates interventions in collaboration with the healthcare team Participates in hospital and department quality improvement initiatives. Qualifications Required: Licensed Registered Nurse in the state of Illinois (IDFPR) Three years of experience in acute inpatient hospital care Organizational, team building, coaching, and conflict management to maximize the achievement of utilization outcomes. Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions. Computer skills including word processing and spreadsheets. Preferred : Bachelor’s Degree in Nursing Equal Opportunity Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status. Background Check Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act. Benefits We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more. Sign-on Bonus Eligibility: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.

Utilization Review

Other

2212, UTIL MGMT REVIEW NURSE - ADMIN RN

apartment Memorial Health (IL) location_onSpringfield, IL

$32 - $52 / HOUR