Clinical - Clinical Review Nurse - Prior Authorization - J00927

Job Title: Clinical Review Nurse Prior Authorization



Duration: 12 Months



Location : Remote U.S.



Eligible Time Zones: MST, CST, EST only

Schedule:

• 8:00 AM 5:00 PM CST
• 1-hour unpaid lunch
• Schedule will be one of the following:
  • Sunday Thursday
  • Tuesday Saturday
  • Wednesday Sunday
• No overtime

Position Overview:
The Clinical Review Nurse will support Medicaid and Marketplace prior authorization reviews across multiple states. The role involves reviewing authorization requests within established turnaround times while maintaining high-quality and compliant clinical review standards.

Key Responsibilities:

• Review prior authorization requests for Medicaid and Marketplace members.
• Complete approximately 14 16 reviews per day.
• Ensure reviews are completed within required turnaround times.
• Apply clinical criteria, policies, and regulatory requirements during authorization reviews.
• Maintain a quality score of 95% or higher.
• Accurately document review decisions and support information.
• Work across multiple states and health plans.
• Support process improvement and strategic initiatives while maintaining daily operational responsibilities.
• Collaborate in a fast-paced, team-oriented environment focused on regulatory compliance and operational excellence.

Required Qualifications:

• Graduate of an accredited nursing program or bachelor's degree in nursing.
• LPN or LVN license required.
• 2 4 years of related clinical experience.
• Prior experience performing prior authorization reviews.
• Strong organizational skills and attention to detail.
• Comfortable working with computers and Microsoft Office Suite.
• Must hold an Illinois or Compact/multistate license; candidates without Illinois or Compact licensure will not be considered.

Preferred Qualifications:

• RN license.
• Compact/multistate nursing licensure.
• Experience with Medicaid and/or Marketplace health plans.
• Experience working with multiple state health plans.

Top Must-Have Skills:

• Prior authorization review experience.
• Strong organization and attention to detail.
• Proficiency with computers and Microsoft Office Suite.