Clinical Review Nurse – Concurrent Review

Centene Corporation

. Complete timely inpatient utilization reviews against medical necessity criteria, health plan policies, and applicable standards .

Posted 9/23/2026full-timeRemote • Florida • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in inpatient utilization reviews, clinical documentation, and care coordination while ensuring compliance with health plan policies and standards. Proficient in managing case volumes and collaborating with healthcare providers to optimize patient care and discharge planning.

Highest-signal resume keywords

Inpatient Utilization ReviewAcute Care ExperienceLPN State LicensureRN LicenseUtilization Management Processes

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Record ReviewMedical Necessity CriteriaQuality ReviewConcurrent ReviewDischarge PlanningCare CoordinationDocumentation AccuracyHealth Management SystemsAcuity Level AssessmentResource Consumption Analysis

Soft Skills

CollaborationCommunicationLeadership FeedbackProblem-SolvingClinical Expertise Sharing

Certifications & Qualifications

Licensed Practical Nurse (LPN)Registered Nurse (RN) License

Industry Keywords

Medicare RegulationsMedicaid RegulationsHealth Plan PoliciesCompliance ActivitiesCare Management

About the role

Key responsibilities & impact

Complete timely inpatient utilization reviews against medical necessity criteria, health plan policies, and applicable standards
Review clinical records and document decisions accurately
Refer appropriate cases for medical director review
Work with providers, facilities, and internal teams to coordinate care and support discharge planning
Assist with quality reviews, audits, and compliance activities
Manage daily case volume while meeting quality, turnaround time, and productivity expectations
Share clinical expertise with teammates and raise recurring issues or improvement opportunities to leadership
Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
Review acuity level, resource consumption, length of stay, quality, continuity of care, 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 appropriate care levels and medical necessity
Review transfer and discharge plans to support timely transitions
Collaborate with care management on member referrals
Perform other duties as assigned

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
LPN (Licensed Practical Nurse) state licensure required
For Health Net of California: RN license required
For State of Nevada: RN (Registered Nurse) state licensure and/or compact state licensure required
Clinical knowledge and ability to determine overall health, treatment needs, and appropriate level of care preferred
Knowledge of Medicare and Medicaid regulations preferred
Knowledge of utilization management processes preferred
Comply with all policies and standards

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
Equal opportunity employment