Clinical Review Nurse – Prior Authorization

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.

Work Location
This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours.

Licensure Requirement
Active and unrestricted New York State Registered Nurse (RN) licensure is strongly preferred for consideration.

Schedule
This position follows a Monday–Friday schedule from 8:30 AM to 5:00 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours.

Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

  • Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
  • Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
  • Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
  • Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care
  • Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
  • Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines
  • Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
  • Provides feedback on opportunities to improve the authorization review process for members
  • Performs other duties as assigned
  • Complies with all policies and standards

Education/Experience: Requires a degree from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.

  • Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
  • Knowledge of Medicare and Medicaid regulations preferred.
  • Knowledge of utilization management processes preferred.


License/Certification:

  • LPN - Licensed Practical Nurse - State Licensure required
  • For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT.

Pay Range: $27.02 - $48.55 per hour

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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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.


Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Additional Information

Company: Centene

Location: New York

Salary: $27.02 - $48.55 per hour

Job ID:

Specialties: Prior Authorization, Clinical Review Nurse

Required Licenses: RN, LPN/LVN

Experience Level: 1-3 years

Back to blog

Other Jobs To Apply

Remote Customer Support Specialist- Part Time & Full Time

PACS Admin with Site co-ordinator (reputed company and Divrad)

Social Media Lead (m/w/d) | Strategie & Performance | 100 % remote

**Experienced Online Customer Support Specialist – reputed company Chat Support (Remote) – Part-Time Opportunity**

Junior Level/ Entry Level Software Engineer (Remote)

Ramp Agent - Evening Shift

Work from Home Overnight Jobs Late Night Customer Experience Specialist $25-$35/hr ? Enhance customer experiences during late-night hours in a home-based role.

Warehouse Associate - Night Shift- Immediate Hiring

reputed company Careers - Find flexible, work-from-home jobs helping customers while earning $25-$35 per hour.

Call Center Representative- Reno, Nevada- Remote (Any city, NV, US, 99999)

Nurse Consultant (Nursing Home Surveyor)

Warehouse Worker Job at Hayes Company LLC in Forney

SOC Analyst I (Remote)

Remote Part‑Time Customer Service Representative – Flight Operations & Passenger Support – Earn $27/hr at arenaflex

Live Chat Jobs - Remote Position (Up to $35/hour) - No Degree Required, No Experience Necessary

[Remote] DR Systems PACS Administrator / Specialist

-Work From Home Position | Entry-Level | Flexible Hours

Flexible Part-Time Remote Data Entry Specialist | Flexible Hours & Training Provided | Join arenaflex Team

reputed company, Progressive Care, Per-diem

Remote Physical Therapist in ID

Overnight Positions Near Me Online – Non-Phone Digital Chat Role | $25–$35/hr

reputed company RN – Clinical Documentation Specialist – CDIP CCDS Required – 100% Remote, GA

HelpDesk (Customer Support)

Senior Technical Program Manager, Amazon Access - Apply

Entry Level Financial Protection Specialist (Remote)

[Remote] Epic- Clinical Service Desk Specialist-REMOTE

Work from Home as a Game Tester in the United States

Medical Scribe (Remote - Full Time) - Full-time

Part Time Package Handler (Twilight) - YVR Area

Lead Backend Developer – Aviation Systems (Remote, Full-Time)

Remote Cybersecurity Jobs - reputed company

Appeals Nurse (RN) Analyst (670084)

Dealer Development Manager (Nashville, TN)

Entry-Level Data Entry Specialist Remote

Part-Time Remote Typist/Data Entry Clerk

No Experience Necessary | Work from Home Chat Agent Job - $25-$35/hour (Remote), Compensation: $25-$35/hour

**Remote Data Entry Clerk – Part‑Time, Precision‑Focused, Flexible Hours, Global Collaboration**

Remote Product Support Representative (No Degree Required/High Paying)

Entry-Level Data Entry Clerk – No Experience Required – Immediate Start at arenaflex – Grow Your Career in a Dynamic Data‑Driven Environment

**Dedicated Overnight Live Chat Support Agent – Remote, Night Shift Customer Service Specialist with Strong Communication Skills**

**Customer Service & Support Representative – Remote – 6+ Month Engagement – Join arenaflex’s Dynamic Operations & Assurance Team**

Experienced Remote Administrative Support & Data Entry Assistant – Part-Time, Entry Level | Flexible Hours + Great Pay

Weekend Job / Part-time Job - Online Tutor in Türkiye

[Remote] Business Operations Admin

Remote Live Chat & Email Support Specialist – Deliver Outstanding Customer Service from Home, Earn $25–$35 per Hour

Customer Support Jobs No Phone Flexible Schedule – reputed company | $25–$35/hr

**Remote Admin Support - Data Entry Role at blithequark**

**Experienced Customer Support Representative – Night and Weekend Shift – Coppell, TX**

Part-Time Remote Live Chat Support Specialist – No Experience Required, Flexible Hours, Earn Up to $280 Daily

**Experienced Part‑Time Remote Data Entry & Market Research Specialist – Earn Competitive Pay in Paid Focus Groups & Clinical Trials**