Teams at Centene Corporation

Reviews prior authorization requests for medical necessity, appropriateness, and benefit coverage. Coordinates with providers, medical directors, and internal teams; documents clinical information; supports transfers and discharge planning; educates stakeholders on utilization processes; and promotes compliant, high-quality, cost-effective care. Requires an active New York RN license, nursing education, and related clinical experience.

Performs concurrent utilization reviews to assess members’ health, medical necessity, acuity, resource use, length of stay, appropriate care settings, and discharge plans. Documents findings, collaborates with Medical Affairs, Medical Directors, providers, and care management, supports medical determinations, educates providers on utilization processes, and identifies opportunities to improve care appropriateness and medical necessity.

Provides consultative support to healthcare providers by analyzing performance, member engagement, quality, utilization, cost, and risk data. Develops reports and presentations, facilitates performance improvement discussions, educates providers on value-based performance tools, and presents Health Benefits Ratio analyses for operating committee meetings. Requires collaboration with health plan quality teams and provider reimbursement expertise.