Senior RN Clinical Review Nurse - Prior Authorization

Support Centene's Fidelis state plan by reviewing complex prior authorization requests to determine medical necessity and appropriate level of care, in accordance with national standards, regulatory guidelines, and members' benefit coverage. Perform clinical reviews of authorization requests, collaborate with healthcare providers and the authorization team to ensure timely turnaround, and escalate cases to Medical Directors when appropriate. Manage service authorization requests for member transfers and discharge plans to ensure smooth transitions between levels of care. Provide feedback on opportunities to improve the authorization review process, and partner with utilization management and care management teams to assess medical necessity. Review member clinical information in health management systems to ensure regulatory compliance. Provide education to providers and internal teams on utilization processes, and act as a trainer to other team members on the prior authorization process. Requires graduation from an accredited school of nursing or BSN, 4–6 years of related experience, and active NY RN licensure. Strong knowledge of Medicare/Medicaid regulations and utilization management processes preferred. Pay range: $30.58–$55.09/hour.