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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 interdepartmental teams to enhance the authorization review process.
Highest-signal resume keywords
Clinical ReviewMedical Necessity AnalysisUtilization Management ProcessesTexas RN LicenseMedicare 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
Prior Authorization AnalysisClinical DocumentationRegulatory ComplianceHealthcare CoordinationService Authorization Requests
Soft Skills
Interpersonal CommunicationFeedback ProvisionEducation And Training
Tools & Technologies
Health Management Systems
Certifications & Qualifications
Registered Nurse (RN)
Industry Keywords
Medical NecessityAuthorization RequestsHealthcare ProvidersInterdepartmental TeamsUtilization 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 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 member transfer or discharge service authorization requests
- Collect, document, and maintain members’ clinical information in health management systems
- Educate 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 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
- Texas RN license required
- 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