Centene Corporation Correspondence Review Nurse I (Baton Rouge, LA or Lafayette, LA) in Baton Rouge, Louisiana

Description:

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

Qualifications:

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. Acute care experience preferred Knowledge of healthcare and managed care preferred.

Follow complex procedures for composition of denial letters.

Follow clinical guidelines on which adverse decisions are based.

Complete accurate adverse decision notifications within specific timeframes.

Licenses/Certifications: Current state s LPN/LVN or RN license.

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

Organization: LA Healthcare Connections

Location: Louisiana-Baton Rouge

Requisition ID: 1061908