Clinical Review Nurse – Concurrent Review, NICU
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Job Description
Clinical Review Nurse conducting concurrent NICU reviews for Centene’s Medicaid and marketplace members. Evaluating medical necessity, care levels, and discharge planning remotely.
Responsibilities:
- Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
- Review quality and continuity of care, acuity level, resource consumption, length of stay, and discharge planning
- Work with Medical Affairs and/or Medical Directors to discuss member care
- Collect, document, and maintain concurrent review findings, discharge plans, and actions taken in member medical records and health management systems
- Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and review findings
- Educate providers on utilization processes
- Provide leadership feedback on opportunities to improve appropriate level of care and medical necessity
- Review member transfer or discharge plans to ensure timely discharge between levels of care and facilities
- Collaborate with care management on member referrals
- Support Medicaid and Ambetter/marketplace insurance members
- Comply with all policies and standards
- Perform other duties as assigned
Requirements:
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- 3+ years of level III or IV NICU experience
- 2+ years of acute care experience
- LPN state licensure required
- RN state licensure and/or compact state licensure for State of Nevada required
- Ability to achieve licensures in non-compact states
- Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred
- Knowledge of Medicare and Medicaid regulations preferred
- Knowledge of utilization management processes preferred
- NICU certification helpful
- Prefer applicants residing in either central or eastern time zones
Benefits:
- Competitive pay
- Health insurance
- 401K plan
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Cost reimbursement for achieving licensure in non-compact states
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