This is currently a work from home position. We continue to assess the market to ensure the safety of our employees and anticipate offering flexible work solutions in the future that are designed to meet the needs of our employees and members.
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 determinations
Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
Educate providers on utilization and medical management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team staff
Enter and maintain pertinent clinical information in various medical management systems
Interact with providers to educate and direct care to participating network providers
Participate in utilization management committees and work on special projects related to utilization management as needed
Qualifications Education/Experience: Graduate from an Accredited School of Nursing. Bachelors degree in Nursing preferred. 2+ years of clinical nursing experience and 1+ 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.For New Hamphsire Healthy Families: Candidates with active nursing licenses in good standing in other states than NH, must obtain the NH equivalent within 90 days of hire. Active drivers license in good standing preferred. RN license required within Utilization Management at Superior HealthPlan.For PA Health & Wellness only: RN required 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. Job: Clinical & Nursing Primary Location: USA-California-Sacramento Other Locations: USA-California-Fresno, USA-California-El Centro, USA-California-San Diego, USA-California-Woodland Hills Organization: Health Net of California Schedule: Full-time