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Centene Corporation Senior Concurrent Review Nurse in Tampa, Florida

Position Purpose:

  • Perform onsite review of emergent/urgent and continued stay 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 discharge planning team electronically, telephonically, or onsite to coordinate member care

  • Conduct discharge planning

  • 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

  • Direct care to participating network providers

  • Participate in utilization management committees and work on special projects related to utilization management as needed

  • Serve as a subject matter expert for questions or issues for other Concurrent Review Nurses and Prior Authorization Nurses

  • Audit case reviews to ensure compliance with utilization management policies and procedures

  • Assist with the development of utilization management workflows, policies, and procedures

  • For New Hampshire: In addition to the above bullets, home visits required.

  • For Arizona Complete Health, in addition to the above bullets:

  • Research and validate accuracy of lapsed authorization data with staff and provide reports summarizing results

  • Lead and facilitate multiple weekly rounds with staff, medical directors, and external contracted providers

  • Assist with training for new hires and continued development of existing staff

  • Serve as a back up to direct manager as needed

  • For Sunflower Health Plan:

  • In addition to the above bullets, oversee the day to day process and productivity for staff and be the go to for any process related questions.Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

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’s LPN/LVN or RN license. For New Hampshire Healthy Families: Candidates with an active nursing license in good standing in other states than NH, must obtain the NH equivalent within 90 days of hire. Active driver’s license in good standing preferred. RN license required within Utilization Management at Superior HealthPlan. 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. TITLE: Senior Concurrent Review Nurse LOCATION: Tampa, Florida REQNUMBER: 1241070 COMPANY: Clinical & Care Management POSITION TYPE: Both

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