Clinical Review Nurse - Prior Authorization {176965}

Job Description

Job Description

Title: Clinical Review Nurse - Prior Authorization
Location: Remote - PST and CST
Pay: $40-$43 per hour
Schedule: Monday-Friday, Sunday-Thursday, or Tuesday-Saturday; shifts may be 7am-4pm, 8am-5pm, 9am-6pm, or 10pm-7pm
Employment Type: W2 Assignment - 12 months, with potential for extension or conversion to FTE based on business needs

About the role

We are seeking a Clinical Review Nurse to support a healthcare organization’s Utilization Management team. This role focuses specifically on prior authorization and pre-service clinical review. You’ll evaluate authorization requests to determine whether requested services are medically necessary and appropriate based on clinical criteria, regulatory requirements, member benefits, and established guidelines.

The position involves reviewing a range of authorization requests, including more complex cases that may require additional clinical consideration. You’ll use your nursing judgment and Utilization Management experience to make appropriate determinations, document your findings, and provide recommendations to the medical team when needed.

What you’ll do

• Perform clinical reviews of prior authorization and pre-service requests to determine medical necessity and appropriateness of care.
• Apply established clinical criteria, regulatory guidelines, benefit requirements, and Utilization Management policies when reviewing cases.
• Handle more complex authorization requests and provide recommendations to the appropriate medical team.
• Review cases using InterQual or MCG/Milliman criteria.
• Document clinical findings, determinations, and recommendations accurately.
• Manage multiple cases independently while meeting established productivity and quality expectations.
• Adapt to changing processes, priorities, and technology while maintaining attention to detail.
• Collaborate with other clinical team members when cases require additional review or escalation.

What you’ll need

• Active RN or LPN state license.
• Graduate of an accredited nursing program or Bachelor’s degree in Nursing.
• 2-4 years of direct experience in prior authorization or pre-service Utilization Management is required.
• Experience performing medical necessity or clinical reviews of authorization requests.
• Experience with InterQual or MCG/Milliman clinical criteria.
• Knowledge of Utilization Management policies and regulations.
• Strong organization, attention to detail, and ability to work independently.
• Ability to make sound clinical decisions and manage a steady volume of work.
• Strong computer skills and comfort learning and adapting to new systems and processes.

Important experience requirement

Direct prior authorization or pre-service Utilization Management experience is required for this position. General nursing experience, medical billing or coding, telephonic care coordination, triage, or other related healthcare experience does not substitute for the required prior authorization/Utilization Management experience.

Additional information

• This is a fully remote position supporting PST and CST schedules.
• Multiple schedule options are available, including Monday-Friday, Sunday-Thursday, and Tuesday-Saturday.
• Candidates should be comfortable working independently while collaborating with a clinical team.