Clinical Review Nurse – Concurrent Review

Remote from: USA
Salary, yearly, USD: 54,000 - 98,000
Department: Healthcare & Medical
Employment type: Full Time,
Job posted: 20 Jul 2026
Apply before: 20 Aug 2026
Experience level: Midweight
Views / Applies: 108 / 2

Transforming the health of the community, one person at a time.

Hospital & Health Care
1984

AI Summary

This role involves performing concurrent reviews of member care to determine medical necessity, appropriate level of care, and discharge planning. The Clinical Review Nurse collaborates with healthcare providers and medical directors to ensure high-quality, cost-effective care. Requires an RN or LPN license and 2-4 years of experience, including 2+ years in acute care. Knowledge of Medicare/Medicaid and utilization management is preferred. The position is remote with on-call weekend and holiday rotations.

Role DNA

Job Complexity

Easy Hard

Pace & Pressure

Relaxed Fast-paced

Autonomy Level

Guided Full Ownership

Communication Load

Independent Highly Collaborative

AI Insight The role requires clinical judgment and knowledge of utilization management, but follows established guidelines and receives support from medical directors, making it moderately difficult.

Salary Analysis

AI Insight The offered salary range of $54,000 to $98,000 annually is competitive for a Clinical Review Nurse position, aligning with the national average for similar roles. The median of $76,000 reflects the experience and licensure required.

Core Skills Required

Utilization Review Concurrent Review Clinical Nursing Medicare Medicaid Care Coordination Discharge Planning Medical Necessity Acute Care Registered Nurse

Cover Letter Sample

Dear Hiring Manager,

I am writing to express my interest in the Clinical Review Nurse - Concurrent Review position at Centene. With a BSN and over 3 years of acute care experience, I have developed strong clinical assessment skills and a deep understanding of medical necessity and discharge planning.

In my previous role, I conducted concurrent reviews, collaborated with interdisciplinary teams, and ensured compliance with utilization management policies. My knowledge of Medicare and Medicaid regulations will allow me to contribute effectively to your team.

I am excited about the opportunity to work remotely and support Centene's mission of providing high-quality, appropriate care to members. Thank you for considering my application.

Sincerely,
[Your Name]

Sample Interview Questions

Describe your experience with concurrent review and how you determine medical necessity.

In my previous role, I reviewed inpatient cases daily, using InterQual and MCG criteria to assess the appropriateness of the level of care. I worked closely with physicians to clarify clinical details and ensured documentation supported continued stay or discharge.

How do you handle conflicts when a provider disagrees with your utilization review decision?

I would first listen to the provider's perspective and review the clinical evidence. If necessary, I would escalate to the Medical Director for a peer-to-peer discussion, maintaining a collaborative approach to ensure the best outcome for the member.

Can you explain the importance of discharge planning in concurrent review?

Discharge planning is crucial to ensure timely and safe transitions, reduce readmissions, and optimize resource use. I coordinate with case managers, social workers, and families to arrange post-acute services and communicate plans with the care team.

What experience do you have with Medicare and Medicaid regulations?

I have worked with Medicare Advantage and Medicaid managed care plans, understanding coverage guidelines and regulatory requirements. I have applied CMS criteria and state-specific policies in my reviews to ensure compliance.

How do you prioritize your workload when handling multiple concurrent reviews?

I assess urgency based on clinical complexity and length of stay, focusing on critical cases first. I use time management tools and communicate with the team to ensure all reviews are completed within required timelines, especially during on-call rotations.

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.

This is a remote role. This position has on call weekend and holiday rotations

Position Purpose: Performs concurrent reviews, including determining member’s overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate
Performs other duties as assigned.
Complies with all policies and standards.

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.
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.
License/Certification:

LPN – Licensed Practical Nurse – State Licensure required

Preferred Qualifications

RN-Registered Nurse-State Licensure and/or Compact State Licensure

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

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