- Performs complex concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
- Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
- Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
- Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
- Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
- Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences
- Manages and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
- Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
- Provides education to providers on utilization processes to ensure high quality appropriate care to members
- Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
- Collaborates with care management on referral of members as appropriate
- Starts to become a subject matter expert based on prior experience
- Performs other duties as assigned
- Complies with all policies and standards
- LPN - Licensed Practical Nurse - State Licensure required
- RN - Registered Nurse preferred Pay Range: $ $52.98 per hour
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Senior Clinical Review Nurse - Tucson, United States - Centene Corporation
Description
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
This is a remote role - MTN or PST preferred.
Position Purpose: Assesses and reviews complex concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assesses complex inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 4 – 6 years of related experience. 2+ years of acute care experience required.
Advanced clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Strong knowledge of Medicare and Medicaid regulations preferred.
Strong knowledge of utilization management processes preferred.
License/Certification:
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
