Clinical Review Nurse - Prior Authorization

Spectraforce Technologies, Inc.; Las Vegas (NV); Remote; USD 80,000 - 105,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse - Prior Authorization for remote work with PST/CST alignment. The role evaluates pre-authorization requests to confirm medical necessity and appropriate care levels per standards and payer coverage.

The ideal candidate has an RN license with 2–4 years of PA experience, knowledge of InterQual/Milliman, and strong organizational skills to support fast-paced clinical decisions.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2-4 years of related experience
• Preferred NV or Compact RN license

Responsibilities

• Review prior authorization requests for medical necessity and appropriate level of care according to standards and coverage.
• Assess complex requests and provide recommendations to the medical team to promote quality and cost effectiveness of care.

Skills

Prior Authorization

InterQual/Milliman

Organizational Skills

Education

Nursing degree (RN)

Job description

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote - PST and CST-(No CA and NY candidates please) / Preferred: NV or Compact RN license

Assignment Duration: 12 months

Work Schedule

Mon - Fri (rotational weekends and holidays)

Sun - Thur

Tues - Sat

Possible shifts in both PST and CST

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

Work Arrangement: Remote

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.

Candidate Requirements

Education/Certification

Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2-4 years of experience

Licensure

Required: 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

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

• Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
• Experience in InterQual or Milliman
• Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.