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Clinical Review Nurse – Concurrent Review
Centene Corporation. Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in concurrent reviews, discharge planning, and utilization management processes while ensuring compliance with Medicare and Medicaid regulations. Possesses strong clinical knowledge and leadership skills to improve member care and facilitate timely transitions between levels of care.
Highest-signal resume keywords
Registered Nurse State LicensureAcute Care ExperienceUtilization Management ProcessesNeonatal Level II or IV NICU ExperienceMedicare and Medicaid Regulations Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Concurrent ReviewDischarge PlanningClinical KnowledgeHealth Management SystemsMedical DeterminationsCare Management CollaborationAcuity Level ReviewResource Consumption AnalysisTreatment Needs AssessmentLeadership Feedback
Soft Skills
Provider EducationCollaborationCommunication
Certifications & Qualifications
Licensed Practical NurseRegistered NurseNICU Certification
Industry Keywords
MedicareMedicaidUtilization ManagementHealthcare ProvidersMember Care
About the role
Key responsibilities & impact- Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
- Review acuity level, resource consumption, length of stay, and discharge planning
- Work with Medical Affairs and/or Medical Directors regarding member care
- Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems
- Work with healthcare providers to approve medical determinations or provide recommendations
- Educate providers on utilization processes
- Provide leadership feedback on opportunities to improve level of care and medical necessity
- Review transfer and discharge plans to ensure timely transitions between levels of care and facilities
- Collaborate with care management on member referrals
- Comply with all policies and standards and perform other assigned duties
Requirements
What you’ll need- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 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
- LPN — Licensed Practical Nurse — State Licensure required
- RN — Registered Nurse — State Licensure and/or Compact State Licensure for State of Nevada required
- Minimum of 3 years neonatal level II or IV NICU experience ideal
- NICU certification is a plus
- Compact nursing licensure preferred or ability to achieve licensure in other states, e.g. CA, OR, IL, MI or NV
- Availability Monday–Friday, 8am–5pm based on applicant’s residence time zone, including rotational weekends and holidays
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation