Remote Clinical Review Nurse

Remote Prior Authorization Registered Nurse

We are seeking experienced Registered Nurses (RNs) to join a remote Prior Authorization team supporting Dual Eligible (Medicare and Medicaid) populations. In this role, you will review outpatient authorization requests, assess medical necessity, apply clinical guidelines, and ensure members receive timely and appropriate access to care. You will work collaboratively with providers, medical directors, and interdisciplinary teams while helping maintain high-quality, cost-effective healthcare services.

Responsibilities

• Perform medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria.
• Collaborate with healthcare providers and the authorization team to ensure timely review of services and/or requests, ensuring members receive authorized care.
• Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of care for members.
• Escalate prior authorization requests to Medical Directors as appropriate to determine the appropriateness of care.
• Assist with service authorization requests for members' transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collect, document, and maintain all members' clinical information in health management systems to ensure compliance with regulatory guidelines.
• Provide education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
• Offer feedback on opportunities to improve the authorization review process for members.
• Comply with all policies and standards.

Essential Skills

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience in clinical review, utilization management, prior authorization, or case management.
• LPN - Licensed Practical Nurse - State Licensure required.
• RN license required for Health Net of California and Superior Health Plan.
• Experience in analyzing authorization requests and determining the medical necessity of services.

Additional Skills & Qualifications

• Clinical knowledge and ability to analyze authorization requests preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• RN Compact License.

Work Environment

This is a remote position, ideal for those who thrive in a fast-paced environment. The role involves working collaboratively with a team of healthcare professionals to ensure high-quality, cost-effective healthcare services. The work requires the use of health management systems and adherence to regulatory guidelines.

Job Type & Location

This is a Contract to Hire position based out of Sunrise, FL.

Pay and Benefits

The pay range for this position is $38.00 - $44.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Oct 8, 2026.