Prior Authorization Nurse II

Centene Corporation

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 Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.

• Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
• Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
• Educate providers on utilization and medical management processes
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff
• Enter and maintain pertinent clinical information in various medical management systems
• Interact with providers to educate and direct care to participating network providers
• Participate in utilization management committees and work on special projects related to utilization management as needed

Education/Experience Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience and 1+ years of utilization management experience in a managed care setting. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs.

Licenses/Certifications Current State LPN/LVN or RN License.

Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Pay Range $25.44 - $45.76 per hour

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

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.

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