Position Purpose\\: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinationsComplete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findingsCollaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member careEducate providers on utilization and medical management processesProvide clinical knowledge and act as a clinical resource to non-clinical team staffEnter and maintain pertinent clinical information in various medical management systemsInteract with providers to educate and direct care to participating network providersParticipate in utilization management committees and work on special projects related to utilization management as neededServe as a subject matter expert for questions or issues for other Utilization Review Nurses and Referral SpecialistsAudit case reviews to ensure compliance with utilization management policies and procedures
Assist with the development of utilization management workflows, policies, and procedures
Education/Experience\\: Graduate from an Accredited School of Nursing. Bachelor s degree in Nursing preferred. 2+ years of clinical nursing experience and 3+ years of utilization management experience in a managed care setting. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs.Licenses/Certifications\\: Current State LPN/LVN or RN License.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.