C

Centene

Runs government-backed health insurance plans

RN Clinical Review Nurse - Prior Authorization

Full-TimePosted on 10/21/2026
$27.02 - $48.55/hr
Mid, Senior
Bachelor's
New York, NY, USA
Remote
Medical, Clinical & Veterinary

About the job

Requirements
  • Requires graduation from an accredited school of nursing or a bachelor's degree in nursing and 2–4 years of related experience.
  • For Fidelis Plan only, a clinical degree as a healthcare professional and the appropriate license are required; examples include Nursing, Physical Therapy, and Occupational Therapy.
  • A Licensed Practical Nurse state license is required.
Responsibilities
  • Analyze prior authorization requests to determine medical necessity and appropriate level of care in accordance with national standards, contractual requirements, and member benefit coverage.
  • Provide recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
  • Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
  • Work with healthcare providers and the authorization team to ensure timely review of services and requests so members receive authorized care.
  • Coordinate with healthcare providers and interdepartmental teams, as appropriate, to assess the medical necessity of member care.
  • Escalate prior authorization requests to Medical Directors, as appropriate, to determine appropriateness of care.
  • Assist with service authorization requests for a member’s transfer or discharge plans to ensure timely discharge between levels of care and facilities.
  • Collect, document, and maintain members’ clinical information in health management systems to ensure compliance with regulatory guidelines.
  • Assist with educating providers and interdepartmental teams on utilization processes to promote high-quality and cost-effective medical care to members.
  • Provide feedback on opportunities to improve the authorization review process for members.
  • Perform other duties as assigned.
  • Comply with all policies and standards.
Desired Qualifications
  • Clinical knowledge and the ability to analyze authorization requests and determine medical necessity of service are preferred.
  • Knowledge of Medicare and Medicaid regulations is preferred.
  • Knowledge of utilization management processes is preferred.

About the company

Centene runs government-backed health insurance plans in the United States, with Medicaid as its largest business alongside Medicare and Affordable Care Act Marketplace coverage. It is one of the largest Medicaid insurers in the country and also runs plans for people eligible for both Medicare and Medicaid, long-term care and children in foster care. States and the federal government pay Centene a set amount per member to manage care, and individuals buy its Ambetter Marketplace plans, often with federal subsidies. Centene contracts with local doctors, hospitals and pharmacies and keeps the difference between premiums and the cost of care. The company was founded in 1984 in Milwaukee and is headquartered in Clayton, Missouri.

Company Size

10,001+

Company Stage

IPO

Headquarters

Clayton, Missouri

Founded

1984

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Simplify Jobs

Simplify's Take

What believers are saying

  • Profits are recovering: July 2026 results lifted full-year adjusted EPS guidance above $4.80.
  • Revenue keeps growing: second-quarter revenue reported in July 2026 rose nearly 10% to about $53.6 billion.
  • Large employer, many paths: Centene had 59,800 employees in June 2026 across Medicaid, Medicare and Marketplace plans.

What critics are saying

  • Job security is shaky: in June 2026 Centene offered buyouts to most employees after steep membership losses.
  • Exchange enrollment is shrinking: Marketplace members fell from about 5.9 million in June 2025 to 3.5 million in June 2026.
  • Revenue rides on Medicaid rolls: enrollment fell 5.5% in a year to 12.1 million by June 2026.

What makes Centene unique

  • Government coverage is the whole business: Centene serves more than 1 in 15 Americans across all 50 states.
  • It began as a safety-net plan: a former hospital bookkeeper founded it in 1984 to serve Milwaukee's low-income patients.
  • It runs specialty Medicaid: its Superior HealthPlan has been Texas's sole foster care insurer since 2008.

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Benefits

  • Health Insurance
  • 401(k) Retirement Plan
  • 401(k) Company Match
  • Paid Vacation
  • Hybrid Work Options
  • Flexible Work Hours

Company News

Trefis
Oct 21st, 2026
The 52-week-high list: 23 Mid Cap names on Tuesday.

The 52-week-high list: 23 Mid Cap names on Tuesday. October 21st, 2026 · by Trefis Team SPYYTD+14.0% SPYYTD+14.0% QQQYTD+18.3% As of Tuesday, October 20, there are 23 Mid Cap US and Canada-listed stocks in the Trefis coverage universe trading at their 52-week highs. Mid Cap here means a market value between $10 billion and $40 billion, the upper figure excluded. At about $35.9 billion in market value, Biogen (BIIB) is the largest company on the list; its stock is up 11.0% over the past month and up 70.0% over the past year. Health Care contributed the most names, 7 of the 23. For context, the S&P 500 is down 0.6% over the past month, including dividends. The 10 Largest, By Market Cap The table below shows the 10 largest of the 23 names, sorted by market capitalization, with returns over four windows: | Tickers | Market Cap | 1D Return | 1W Return | 1M Return | 1Y Return | | BIIB | $35.9 Bil | 4.1% | 6.2% | 11.0% | 70.0% | | CNC | $35.0 Bil | 3.2% | 2.8% | 9.0% | 100.8% | | WSM | $29.9 Bil | 1.8% | 6.2% | 12.1% | 38.9% | | SN | $28.1 Bil | 5.2% | 5.3% | 18.6% | 111.6% | | WST | $27.5 Bil | 1.3% | 4.6% | 7.5% | 44.1% | | CHD | $25.1 Bil | 1.8% | 5.8% | 11.0% | 21.3% | | IFF | $23.3 Bil | 0.3% | 3.4% | 9.1% | 46.3% | | PR | $20.8 Bil | 0.2% | 2.4% | 13.1% | 109.1% | | OVV | $19.7 Bil | 0.4% | 5.4% | 16.8% | 99.9% | | APA | $17.6 Bil | 0.3% | 3.9% | 13.9% | 129.3% | The Businesses Behind The Largest New Highs Biogen (BIIB) grew revenue 0.3% over the last twelve months and earned an operating margin of 19.3%. Centene (CNC) grew revenue 13.9% over the last twelve months and earned an operating margin of 0.8%. Across the list, one-month moves range from +6.4% for American Financial (AFG) to +24.9% for Hasbro (HAS). The median stock on the list is up 46.7% over the past year. 9 of the 23 names are also S&P 500 members. A new high tells you what the market already believes. The harder question is which of these runs management itself is underwriting. Our Guidance Momentum screen tracks exactly that: stocks where the company raised its own forward numbers. Strength Is A Clue. It Is Not A Plan A stock at its 52-week high has momentum on its side, and momentum is a real force. It is also the most crowded signal in the market, and what separates a run that lasts from one that tops is usually the business underneath. Checking that business, across thousands of names, is how the Trefis High Quality (HQ) Portfolio is assembled: roughly 30 companies that pass the quality screens, rebalanced on rules. It has a track record of outpacing a benchmark that combines the S&P 500, the S&P MidCap 400, and the Russell 2000. Let the highs point; let the discipline decide.

Yahoo Finance
Oct 14th, 2026
Centene shares rise 6.6% as it launches Gold Card scheme and redeems $568.66M of notes

Centene Corporation announced three moves in October 2026: a performance-based prior authorisation programme, a debt redemption, and a primary care expansion. Its shares are up 6.6%. The National Performance-Based Gold Card Program begins in November 2026. It aims to streamline prior authorisation for more than 160,000 eligible providers. Centene will also redeem all remaining $568.66 million of its 4.25% Notes due 2027. The move tightens its balance sheet as it works to recover margins in Medicaid and the Marketplace. Separately, its Ambetter Health Solutions unit is working with Marathon Health to expand primary care access in select Indiana and Missouri counties.

Fortune
Oct 13th, 2026
Centene CEO says health care's big AI opportunity lies beyond billing automation

Centene chief executive officer Sarah London says most AI deployed in health care today serves "inflationary use cases," tools that raise revenue in a fee-for-service system rather than cut the cost of care. Speaking at the Fortune Most Powerful Women Summit in Santa Barbara, she said faster billing and automated paperwork don't make care cheaper. London sees a bigger opportunity in changing how care is delivered. In rural areas, AI could help community health workers triage non-acute problems locally and avoid emergency room visits. Interactive tools could also let patients make initial decisions without a clinician visit. "That's actually how you bend the cost curve," she said. Centene, a $33 billion company, serves 26 million members through Medicaid plans in 29 states, plus marketplace and Medicare Advantage coverage.

Yahoo Finance
Oct 13th, 2026
Centene shares rise 3.5% on gold card plan to ease prior authorisation for 160,000 providers

Centene shares rose 3.5% in afternoon trading after the health coverage company said it will launch a National Performance-Based Gold Card Program in November 2026. The stock closed at $68.88, up 2.8%. The programme will streamline prior authorisation reviews for select outpatient services. More than 160,000 qualifying healthcare providers nationwide will be eligible. Prior authorisation is the process by which insurers approve medical care before it is delivered. Centene is up 64.9% since the start of the year and close to its 52-week high of $69.41, set in September 2026.

Modern Healthcare
Oct 13th, 2026
Centene to launch prior authorization gold card program.

Centene to launch prior authorization gold card program. Last Updated October 13, 2026 12:06 PM CDT Centene is launching a new program next month aimed at streamlining the prior authorization process for some providers.