RN Clinical Review Nurse – Prior Authorization
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Posted: 10/21/2026RN Clinical Review Nurse – Prior Authorization
Centene CorporationPosted 10/21/2026full-timeRemote • New York • United StatesJuniorMid-Level💰 $27 - $49 per hourWebsite
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 while ensuring compliance with regulatory guidelines. Proficient in collaborating with healthcare providers and interdepartmental teams to enhance the authorization review process and promote quality care.
Highest-signal resume keywords
Clinical KnowledgeMedical Necessity AnalysisUtilization Management ProcessesLPN State LicensureMedicare And Medicaid Regulations
About the role
Key responsibilities & impact- Analyze prior authorization requests to determine medical necessity and appropriate level of care
- Provide recommendations to the appropriate medical team to promote quality and cost-effective care
- Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria
- Work with healthcare providers and the authorization team 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
- Perform other duties as assigned
Requirements
What you’ll need- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 2–4 years of related experience
- LPN (Licensed Practical Nurse) state licensure required
- For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license; examples include Nursing, PT and OT
- 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 plan
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Paid holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
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 ReviewClinical ReviewDocumentation ManagementHealthcare CoordinationRegulatory Compliance
Soft Skills
CommunicationCollaborationProblem-Solving
Tools & Technologies
Health Management Systems
Certifications & Qualifications
Licensed Practical Nurse (LPN)
Industry Keywords
Prior AuthorizationMedical NecessityQuality CareCost-Effective CareInterdepartmental Coordination