Clinical Review Nurse – Concurrent Review

Centene Corporation

. Conduct inpatient concurrent reviews to assess medical necessity using InterQual criteria, corporate and state policies, and available review tools .

Posted 10/2/2026full-timeRemote • Florida • United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting inpatient concurrent reviews and assessing medical necessity using InterQual criteria and state policies. Proficient in collaborating with healthcare providers and care management to ensure appropriate member care and compliance with regulations.

Highest-signal resume keywords

Inpatient Concurrent ReviewInterQual CriteriaMedicaid RegulationsUtilization Management ProcessesRN State Licensure

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical KnowledgeAcute Care ExperienceDischarge PlanningHealth Management SystemsMedical Determinations

Soft Skills

CollaborationLeadership FeedbackProvider Education

Certifications & Qualifications

LPN State LicensureRN State LicensureCompact State Licensure

Industry Keywords

HealthcareMedical NecessityCare ManagementMember ReferralsAcuity Level

About the role

Key responsibilities & impact

Conduct inpatient concurrent reviews to assess medical necessity using InterQual criteria, corporate and state policies, and available review tools
Support New Hampshire Medicaid through the East Region Shared Services team
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 level-of-care and medical-necessity improvement opportunities
Review transfer or 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
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 state licensure required
RN state licensure and/or compact state licensure for the State of Nevada required
Work from 8:00 a.m. to 5:00 p.m. Eastern Time
Required weekend and holiday coverage based on team needs

Benefits

Comp & perks

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