Clinical Review Nurse - Prior Authorization

Position Title

Clinical Review Nurse - Prior Authorization

Work Location

Remote; nationally sourced within approved U.S. states. Must be available during standard business hours for the assigned team.

Assignment Duration

12 Months possibility of extension or conversion

Work Schedule

Monday-Friday, standard business hours. Occasional overtime may be requested based on workload or regulatory deadlines.

Work Arrangement

Remote

Position Summary

The Nurse Reviewer performs clinical review of authorization requests using established clinical criteria, plan benefits, regulatory requirements, and internal policies. Responsibilities include reviewing submitted clinical documentation, determining medical necessity within scope, requesting additional information when needed, documenting decisions accurately, meeting turnaround-time requirements, and escalating cases requiring physician or medical director review.

Background & Context

The team supports timely, accurate, and compliant utilization review to help members receive medically appropriate services. The need is driven by current review volume and the need to maintain service levels and turnaround times. The environment is collaborative, production-oriented, and quality-focused, with close partnership among nurses, supervisors, medical directors, and operational teams. This request supports ongoing operational capacity and may be part of broader staffing needs.

Key Responsibilities

• Prioritizing assigned cases according to urgency and turnaround time
• Reviewing clinical records against applicable criteria and benefits
• Documenting findings
• Communicating requests for missing information
• Escalating cases outside nursing authority
• Responding to questions
• Participating in team huddles or training
• Completing required administrative tasks
• Collaborating with providers and internal clinical and operational teams while maintaining confidentiality, quality, productivity, and compliance standards

Qualification & Experience

Education/Certification: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

Licensure: Required: Active, unrestricted LPN or Registered Nurse license in the applicable state or compact license, as permitted for the assignment.

Years of experience required: 2 or more years of clinical nursing experience; utilization management, managed care, or prior authorization experience preferred.

Disqualifiers: Inactive, restricted, or encumbered nursing license; inability to meet required schedule or remote-work requirements; insufficient clinical documentation skills; or inability to work independently in a productivity-based environment.

Additional qualities to look for: Strong critical thinking, organization, attention to detail, professional communication, adaptability, reliability, and comfort learning clinical systems and review criteria.

Top 3 must-have hard skills stack-ranked by importance

1. Clinical assessment and application of medical-necessity criteria.
2. Accurate, concise clinical documentation and case management within required turnaround times.
3. Proficiency with electronic clinical systems, Microsoft Office, and remote collaboration tools.

Additional Notes

Position is offered by a no fee agency.