Clinical Review Nurse - Prior Authorization

Actalent; Ridgeland (MS); Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated Prior Authorization Nurse to analyze authorization requests and collaborate with medical teams to enhance care quality. This fully remote role offers a chance to work within a supportive environment, ensuring compliance with national standards. Ideal candidates will have a strong clinical background, with the ability to navigate Medicare and Medicaid regulations effectively. Join a team that values quality care and offers competitive pay, along with comprehensive benefits. This is your opportunity to make a meaningful impact in the healthcare sector while enjoying the flexibility of remote work.

Benefits

Medical, dental & vision

401(k) Retirement Plan

Life Insurance

Short and long-term disability

Health Spending Account (HSA)

Transportation benefits

Employee Assistance Program

Time Off/Leave

Qualifications

• 2-4 years of related experience in clinical settings.
• Registered Nurse (RN) preferred.

Responsibilities

• Analyze prior authorization requests for medical necessity.
• Collaborate with healthcare providers for service reviews.
• Document clinical information in health management systems.

Skills

Clinical knowledge

Analytical skills

Familiarity with Medicare and Medicaid regulations

Utilization management processes

Education

Graduate from an Accredited School of Nursing

Bachelor’s degree in Nursing

Current LPN - Licensed Practical Nurse State Licensure

Job description

Clinical Review Nurse - Prior Authorization

Clinical Review Nurse - Prior Authorization

1 day ago Be among the first 25 applicants

Job Description

The Prior Authorization Nurse plays a crucial role in analyzing authorization requests to determine the medical necessity and appropriate level of care according to national standards and contractual requirements. The position involves collaborating with medical teams to enhance the quality and cost-effectiveness of medical care.

Job Title: Prior Authorization Nurse

Job Description

The Prior Authorization Nurse plays a crucial role in analyzing authorization requests to determine the medical necessity and appropriate level of care according to national standards and contractual requirements. The position involves collaborating with medical teams to enhance the quality and cost-effectiveness of medical care.

Responsibilities

• Analyze prior authorization requests to determine medical necessity and appropriate level of care.
• Provide recommendations to medical teams to promote quality and cost-effectiveness of care.
• Conduct medical necessity and clinical reviews to ensure regulatory compliance.
• Collaborate with healthcare providers and the authorization team for timely service reviews.
• Coordinate with healthcare providers and interdepartmental teams to assess medical necessity.
• Escalate prior authorization requests to Medical Directors when necessary.
• Assist with service authorization requests for transfers or discharges to ensure timely transitions.
• Document and maintain member clinical information in health management systems.
• Educate providers and interdepartmental teams on utilization processes to promote quality care.
• Provide feedback to improve the authorization review process.
• Perform other duties as assigned and comply with all policies and standards.
  
  

Essential Skills

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2-4 years of related experience in clinical settings.
• Current LPN - Licensed Practical Nurse State Licensure.
• Clinical knowledge and ability to analyze authorization requests.
• Familiarity with Medicare and Medicaid regulations.
• Understanding of utilization management processes.
  
  

Additional Skills & Qualifications

• Registered Nurse (RN) preferred.
• Prior experience with clinical review preferred.
  
  

Work Environment

This is a 100% remote position with a collaborative team environment. Work hours are Monday to Friday, 8 AM to 5 PM, with rotating weekends. Initial training includes a four-week learning journey followed by preceptor training. Upon completion of training, the expectation is to process 15-17 authorizations per day.

Pay and Benefits

The pay range for this position is $36.00 - $36.00/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 May 2, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [e-mail] for other accommodation options.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Business Consulting and Services

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