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Clinical Review Nurse – Prior Authorization
Centene Corporation. Analyze prior authorization requests to determine medical necessity and appropriate level of care .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in analyzing prior authorization requests and determining medical necessity in compliance with regulatory guidelines. Proficient in coordinating with healthcare providers and utilizing health management systems to maintain clinical information.
Highest-signal resume keywords
Texas RN LicenseClinical ReviewMedical Necessity AnalysisUtilization Management ProcessesMedicare And Medicaid Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Authorization Requests AnalysisClinical KnowledgeDocumentation MaintenanceService Authorization RequestsRegulatory Compliance
Soft Skills
CollaborationCommunicationFeedback ProvisionEducation
Tools & Technologies
Health Management Systems
Certifications & Qualifications
RN License
Industry Keywords
Prior AuthorizationMedical NecessityHealthcare ProvidersInterdepartmental CoordinationUtilization Processes
About the role
Key responsibilities & impact- Analyze prior authorization requests to determine medical necessity and appropriate level of care
- Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria
- Work with healthcare providers and authorization teams to ensure timely review of services and requests
- Coordinate with healthcare providers and interdepartmental teams to assess members’ medical necessity of care
- Escalate prior authorization requests to Medical Directors as appropriate
- Assist with service authorization requests for member transfer or discharge plans
- Collect, document, and maintain members’ clinical information in health management systems
- Provide education to providers and interdepartmental teams on utilization processes
- Provide feedback on opportunities to improve the authorization review process
- Comply with all policies and standards and perform other duties as assigned
Requirements
What you’ll need- Texas RN license required
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 2–4 years of related experience
- Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred
- Knowledge of Medicare and Medicaid regulations preferred
- Knowledge of utilization management processes preferred
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 employment
- Consideration for qualified applicants with arrest or conviction records in accordance with applicable law