Prior Authorization Nurse I

IlliniCare Health Plan Chicago, Illinois

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As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.

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What does it take?

What are the qualities that will help you achieve success in this role at Centene?

Success Profile

Detail-oriented
Trustworthy
Personable
Quick-thinking
Multi-tasker
Good listener

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Quote

“Centene is an exciting company to work for, the pace at which we’re growing allows numerous advancement opportunities. Also, we foster an environment that supports and offers numerous leadership growth opportunities.”
- Esmeralda Baig, SVP Operations, Complex Care Products

“I enjoy the people and the flexibility of my role. As an onsite nurse, I have the pleasure of working with my team at Centene as well as the wonderful team at my onsite hospital.”
- Njeri Young, RN, Concurrent Review Nurse

“I assisted with one of the Provider fairs in the community. Seeing how much we care for our community and our patients was very eye opening.”
- Julie Boulch, Senior Manager of Medical Management Operations

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Responsibilities

Job ID 1130424

Category Clinical & Nursing
Schedule Full-time

Description:
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

Qualifications:

Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred.

Licenses/Certifications: Current State 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.

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Our Medical Roles

Overall Medical Management

A member of the Centene Medical Management team, we innovate and execute strategies that redefine the industry standard for improving the lives and health of people.

Concurrent Review Nurse

To ensure our members get the best quality of care, you’ll assess acute member health conditions, treatment and intervention options, and match them with providers, community and health plan resources.

Prior Authorization Nurse

You’ll ensure our members get the best quality services, assistive devices, and equipment to promote optimal health and independence in the community and help promote health and independence.

Care Manager

Working directly with members, interdisciplinary care team, providers and data analytics, you’ll identify member health risks and conditions and intervention and service options.

LTSS Program Specialist/Program Specialist Field Based

Working directly with our most vulnerable members, you’ll identify individual member health risks and opportunities to enhance independence, quality of life and community engagement.

Referral Specialist

You’ll use our data systems to directly assist providers, requesting services and treatments for our members.

Medical Director

To help support the individual needs of members and develop programs that address issues, you’ll review population health data, help design clinical programs, and develop care delivery partnerships.

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Our Awards

Centene is consistently recognized for how well we treat our members, our people, and the communities we serve.

Honored to be Honored

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Our Hiring Process

Learn more about our hiring process and discover other helpful information for applicants.

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“Flexibility is key. Centene is a company of change.”

Ashley Collier

Started as a Referral Specialist, now a Project Manager IV

See Ashley's career path

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