Clinical Review Nurse

Prior Authorization Nurse (Utilization Review)

This role analyzes prior authorization requests to determine the medical necessity and appropriate level of care in line with national standards, contractual requirements, and members' benefit coverage. The nurse provides informed recommendations to the medical team to support high-quality, cost-effective care and ensures that members receive timely, appropriate services through thorough clinical review and collaboration with healthcare providers.

Responsibilities

• Perform medical necessity and clinical reviews of prior authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines, clinical criteria, and benefit coverage.
• Work closely with healthcare providers and the authorization team to ensure timely review and processing of service requests so that members receive authorized care without unnecessary delays.
• Coordinate with healthcare providers and interdepartmental teams, as appropriate, to assess the medical necessity of care for members and to clarify clinical information when needed.
• Escalate prior authorization requests to Medical Directors when appropriate to obtain determinations on complex or borderline cases and ensure appropriate levels of care.
• Assist with service authorization requests related to member transfers or discharge plans to support timely and safe transitions between levels of care and facilities.
• Collect, document, and maintain comprehensive clinical information for each member in designated health management systems to ensure accuracy, completeness, and compliance with regulatory guidelines.
• Assist in providing education to providers and interdepartmental teams on utilization management and authorization processes to promote high-quality, cost-effective medical care for members.
• Provide feedback and suggestions on opportunities to improve the authorization review process and enhance the member and provider experience.
• Comply with all organizational policies, procedures, and standards while maintaining confidentiality and professional conduct.
• Perform other related duties as assigned to support utilization management and overall care quality.

Essential Skills

• Graduate from an accredited School of Nursing or a bachelor's degree in Nursing.
• Active state licensure as a Registered Nurse
• 3+ years of utilization management experience

Additional Skills & Qualifications

• Registered Nurse (RN) license for roles aligned with specific health plans or regions where required.
• Knowledge of Medicare regulations.
• Knowledge of Medicaid regulations.
• Familiarity with utilization management processes and principles.
• Experience working with health management or utilization review systems.
• Ability to provide clear education and guidance to providers and internal teams regarding utilization processes.
• Strong critical thinking and problem-solving skills for evaluating complex clinical scenarios.
• Commitment to promoting high-quality, cost-effective care and a positive member experience.

Work Environment

The role operates in a structured clinical and administrative environment focused on utilization review and prior authorization. Work typically involves extensive use of computers, electronic health management systems, and other digital tools to review clinical information, document determinations, and communicate with providers and internal teams. The position requires adherence to organizational policies, regulatory standards, and confidentiality requirements. Hours and shifts may align with standard business operations for health plan or utilization management teams, with an emphasis on timely processing of authorization requests and coordination with providers.

Job Type & Location

This is a Contract position based out of Saint Louis, MO.

Pay and Benefits

The pay range for this position is $35.00 - $39.00/hr. 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 Jun 5, 2026.