Clinical Review Nurse:
Description
Duals Program Details- Brand new program of 2026 for Centene
Duals = Medicare + Medicaid line of business. Members have one combined card and one authorization covering both benefit types.
The duals program is currently active in eight states:
Cloud Charting: Delaware, Iowa, Texas
Classic Platform: Arizona, Illinois, Michigan, Ohio, South Carolina
Additional states may be added in 2027.
They are managing both Medicare and Medicaid requirements simultaneously, which increases complexity.
They are handling inpatient concurrent review and average 1.85 cases per hour.
Skills
clinical review, RN license, prior authorization, utilization management, concurrent review, interqual, managed care, medical management, acute care, medicaid, medicare
Additional Skills & Qualifications
Experience:
Prefer RNs with Utilization Management (UM) experience.
Experience with outpatient prior authorization
Strong preference...