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Job Opening details:-
Company Name :- Sunshine State Health Plan
Position Name :-
Company Location :- Florida
Job Category :- General
Full Job Description :-
You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
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
Our Comprehensive Benefits Package:
Flexible work solutions including remote options, hybrid work schedules and dress flexibility
Paid Time Off including paid holidays
Health insurance coverage for you and dependents
401(k) and stock purchase plans
Tuition reimbursement and best-in-class training and development
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: Florida or Compact 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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