Clinical Review Nurse - Prior Authorization

Nurse Reviewer

Location: 100% Remote; nationally sourced within approved U.S. states. Must be available during standard business hours for the assigned team. Shift: Monday–Friday, standard business hours. Occasional overtime may be requested based on workload or regulatory deadlines. Duration: 12 months (Possible extension or conversion based on business need, performance, and budget approval).

Job Profile 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. The role collaborates with providers and internal clinical and operational teams while maintaining confidentiality, quality, productivity, and compliance standards.

Position Purpose: The nurse reviewer begins by prioritizing assigned cases according to urgency and turnaround time, reviews clinical records against applicable criteria and benefits, documents findings, communicates requests for missing information, and escalates cases outside nursing authority. Daily work also includes responding to questions, participating in team huddles or training, and completing required administrative tasks. Performance is measured through quality and documentation accuracy, productivity, turnaround-time compliance, attendance, and adherence to policies. The role offers exposure to varied clinical cases and requires sound judgment within a structured, regulated environment.

Candidate Requirements

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:

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