About the role
Centene is hiring a remote Clinical Review Nurse to perform concurrent reviews of inpatient care for its Health Net of California business. You'll confirm that the level and setting of care are medically necessary and help plan timely discharges. An active California RN license is required, and the schedule follows Pacific time with a weekend and holiday rotation.
Responsibilities
- Perform concurrent reviews to judge a member's overall health, the care being delivered, and the appropriate level of care
- Review acuity, resource use, length of stay, and discharge plans to confirm quality and continuity of care
- Work with Medical Directors and Medical Affairs on member care when needed
- Document concurrent review findings, discharge plans, and actions in health management systems per UM policy
- Approve determinations or recommend alternatives with healthcare providers based on review findings
- Educate providers on utilization processes and refer members to care management as appropriate
Requirements
- Active RN license in California (Health Net of California)
- Graduate of an accredited nursing school or a bachelor's in nursing, plus 2–4 years of related experience
- At least 2 years of acute care experience
- Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific, plus a regular weekend and holiday rotation
- Preferred: knowledge of Medicare and Medicaid regulations and UM processes
What we offer
- Health insurance
- 401(k) and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Remote work
- Incentive compensation may apply