Clinical Review Nurse - Prior Authorization

Spectraforce Technologies, Inc.; Houston (TX); Remote; USD 70,000 - 100,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse - Prior Authorization for a 12-month assignment. The role is remote (PST/CST) with scheduling across multiple shifts, supporting national guidelines and contractual requirements.

You will review PA requests for medical necessity, assess complex cases, and guide the medical team to ensure appropriate care while aligning with compliance standards. RN licensure is required, with preferred NV/Compact credentials.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing with 2–4 years of experience
• RN license in state; NV or Compact RN license preferred
• Prior PA experience with InterQual/Milliman; knowledge of Utilization Management

Responsibilities

• Routinely reviews prior authorization requests to determine medical necessity and appropriate level of care.
• Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

Skills

Utilization Management

Prior Authorization

InterQual/Milliman

Regulatory knowledge

Team player

Education

Nursing degree

RN License

Tools

OneNote

Microsoft Office

Job description

Position Title

Clinical Review Nurse - Prior Authorization

Work Location

Remote - PST and CST (No CA and NY candidates please)

Assignment Duration

12 Months

Work Schedule

Sunday - Thursday

• 7am - 4pm
• 8am - 5pm
• 9am - 6pm
• 10pm - 7pm

Shifts depend on what the team needs. Possible shifts in both PST and CST

Work Arrangement

Remote - PST and CST

Position Summary

Routinely reviews prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Background & Context

UM is highly focused on how we can be better partners to our external stakeholders, answering the question of "how can make it easy to work with us?" Specifically, this role will impact the member and provider experience, and this nurse will be responsible for ensuring communication excellence and unbiased application of policy and state regulations to ensure best possible member health outcomes. Candidates will be particularly interested in the collaborative and supportive team environment, enhanced by a democratic leadership style that values each team member's input and fosters a culture of creativity and continuous improvement.

Key Responsibilities

• Routinely reviews prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage.
• Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.

Qualification & Experience

• Education/Certification: Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience
• Preferred:
• Licensure: Required: RN- Registered Nurse/LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• Preferred: NV or Compact RN license
• Years of experience required: Nice to haves: 2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations), at least 1 candidate must have NV license. Disqualifiers: California and NY candidates. Additional qualities to look for: Team player, flexible
• 1 Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
• 2 Experience in InterQual or Milliman
• 3 Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.