About this role.
This remote Clinical Review Nurse position at Centene involves analyzing prior authorization requests to determine medical necessity and appropriate level of care. The role requires a California RN license and experience in utilization management, with a focus on Medicare and Medicaid regulations. The nurse collaborates with providers and internal teams, escalates cases to Medical Directors, and ensures compliance with regulatory guidelines. Centene offers competitive pay, benefits, and flexible remote work schedules. The position operates on PST hours and requires strong clinical judgment and communication skills.
Role DNA
A quick view of the complexity, pace, ownership and collaboration implied by the job description.
Job Complexity
4/5Pace & Pressure
3/5Autonomy Level
3/5Communication Load
4/5Salary analysis
Estimated compensation compared with the broader US market for similar roles.
Core skills
Skills and capabilities most closely associated with this opportunity.
Cover letter sample
Dear Hiring Manager,
I am writing to express my interest in the Clinical Review Nurse position at Centene. With my Registered Nurse license and extensive background in utilization management and prior authorization, I am confident in my ability to ensure members receive medically necessary and cost-effective care.
In my previous roles, I developed strong skills in analyzing clinical information, applying Medicare and Medicaid regulations, and collaborating with providers to facilitate timely authorization decisions.
I am particularly drawn to Centene's mission to transform healthcare and would be honored to contribute to your team while working remotely in PST hours.
Thank you for considering my application. I look forward to discussing how my experience aligns with this opportunity.
Sincerely, [Your Name]
Sample interview questions
I review the clinical information against evidence-based criteria and national standards, consider the member's benefit coverage, and consult with providers if needed. I escalate complex cases to Medical Directors when appropriate.
I have worked with both Medicare and Medicaid guidelines in my previous utilization management roles, ensuring compliance with CMS requirements and state-specific regulations.
I prioritize by clinical urgency, use systematic documentation, and follow established workflows. I also communicate with the team to manage workload effectively without compromising quality.
In a previous role, I escalated a request that was not clearly meeting criteria due to unusual clinical circumstances. I presented the case summary and the medical director provided guidance for a final decision.
I appreciate the flexibility that remote work offers and I am aligned with Centene's mission to improve member health. The role allows me to use my clinical expertise in a meaningful way while maintaining a healthy work-life balance.
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.
*CA RN required.
* Position is remote. Will work PST 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 Graduate 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.
Hospice experience preferred.
License/Certification:
- For Health Net of California: RN license required
- CA RN required
* Position is remote. Will work PST hours.
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
Upload your resume now
- To unlock remote work opportunities and be discovered by global employers.
This job listing has been manually reviewed by the Jobicy Trust & Safety Team for compliance with our posting guidelines, including verification of the company's legitimacy, accuracy of job details, clarity of remote work policy, and absence of misleading or fraudulent content.
