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Clinical Review Nurse – Concurrent Review
Centene Corporation. Perform concurrent reviews, including determining members’ overall health, reviewing the type of care delivered, evaluating medical necessity, and contributing to discharge planning .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in concurrent reviews, medical necessity evaluations, and discharge planning within healthcare settings. Proficient in collaborating with medical professionals and utilizing health management systems to enhance patient care and compliance with regulations.
Highest-signal resume keywords
Concurrent ReviewMedical Necessity EvaluationAcute Care ExperienceLPN 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 KnowledgeDischarge PlanningCare Management CollaborationHealth Management SystemsAcuity Level Assessment
Soft Skills
Leadership FeedbackProvider EducationCollaboration
Certifications & Qualifications
Licensed Practical Nurse (LPN)
Industry Keywords
Medicare RegulationsMedicaid RegulationsUtilization ManagementMedical AffairsInpatient Services
About the role
Key responsibilities & impact- Perform concurrent reviews, including determining members’ overall health, reviewing the type of care delivered, evaluating medical necessity, and contributing to discharge planning
- Evaluate inpatient services to validate the necessity and setting of care delivered
- Determine appropriate care and setting by reviewing 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 taken in medical records and 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
- Collaborate with care management on member referrals
- Comply with all policies and standards
- Perform other duties as assigned
Requirements
What you’ll need- Must reside in EST or CST
- Med Surg experience highly preferred
- 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
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 employer committed to diversity