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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, care coordination, and compliance activities while effectively managing case volume and collaborating with healthcare teams. Holds relevant nursing licensure and possesses a strong understanding of Medicare and Medicaid regulations.
Highest-signal resume keywords
Inpatient Utilization ReviewAcute Care ExperienceRN LicenseLPN State LicensureUtilization 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 CriteriaDischarge PlanningQuality ReviewsConcurrent ReviewCare CoordinationDocumentation of DecisionsAcuity Level AssessmentResource Consumption AnalysisHealth Management Systems
Soft Skills
CollaborationCommunicationProblem-SolvingLeadershipEducation
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, document decisions, and refer appropriate cases for medical director review
- Coordinate care and support discharge planning with providers, facilities, and internal teams
- 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, and discharge planning
- Collaborate with Medical Affairs, Medical Directors, and care management
- Maintain concurrent review findings, discharge plans, and actions in health management systems
- Approve medical determinations or provide recommendations based on requested services and review findings
- Educate providers on utilization processes
- Review transfer and discharge plans to support timely transitions between care levels and facilities
- Perform other duties as assigned and 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 state licensure required
- RN license required for Health Net of California
- RN state licensure and/or Compact State Licensure required for the state of Nevada
- 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
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K plan
- 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 and consideration under applicable law