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Clinical Review Nurse – Concurrent Review
Centene Corporation. Complete timely inpatient utilization reviews against medical necessity criteria, health plan policies, and applicable standards .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
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 member care and discharge planning.
Highest-signal resume keywords
Inpatient Utilization ReviewAcute Care ExperienceLicensed Practical Nurse (LPN)Medicare and Medicaid KnowledgeUtilization Management Processes
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Record ReviewMedical Necessity CriteriaQuality ReviewDischarge PlanningConcurrent ReviewCare CoordinationDocumentation AccuracyHealth Management Systems
Soft Skills
CollaborationCommunicationLeadership Feedback
Certifications & Qualifications
State Licensure
Industry Keywords
Healthcare ComplianceQuality AssuranceCare ManagementHealth Plan Policies
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 to discuss 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 or discharge plans to ensure timely discharge between levels of care and facilities
- Collaborate with care management on member referrals
- Perform other duties as assigned
- Comply with all policies and standards
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
- 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
- Ability to 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
- Consideration for qualified applicants with arrest or conviction records in accordance with applicable law