Clinical Review Nurse Prior Authorization

SupportFinity™; Town of Clifton (NY); Remote; USD 75,000 - 95,000; Full time

Job summary

A healthcare service company is seeking a Clinical Review Nurse for prior authorization to review and process requests. The role requires an RN California licensure and 2-4 years of related clinical experience. Responsibilities include collaborating with healthcare providers and assessing medical necessity. Position is remote with a duration of 12 months and possibility of conversion to FTE.

Qualifications

• RN California licensure required.
• 2-4 years of related experience in clinical settings.
• Clinical knowledge to analyze authorization requests.

Responsibilities

• Review and process prior authorization requests.
• Coordinate with healthcare providers to assess medical necessity.
• Assist with service authorization requests for member transitions.

Skills

Critical thinking

Organizational skills

Multitasking skills

Tech-savvy

Microsoft Office Suite familiarity

Education

Graduate from an accredited School of Nursing or Bachelor’s degree in Nursing

Job description

Overview

Title: Clinical Review Nurse Prior Authorization

Company: Pacer Group

Location: Remote CA

Duration: 12 months | Possibility to convert to FTE if the position opens

Shift: Training 8-5 PM PST for 4-6 weeks; after training 8-5 PM PST. No time off during training. Camera on. No OT, holidays, or weekends.

Responsibilities

• Review and process prior authorization requests, including processing related letters
• Participate in weekly team meetings (camera on) and monthly one-on-one meetings (camera on)
• Use team chat (Teams) for questions; collaborate with healthcare providers and the authorization team to ensure timely review of services
• Assess medical necessity and clinical appropriateness in accordance with regulatory guidelines and criteria
• Coordinate with healthcare providers and interdepartmental teams to assess medical necessity
• Escalate PA requests to Medical Directors as appropriate
• Assist with service authorization requests for member transfer or discharge planning to ensure timely transitions
• Collect, document, and maintain all member clinical information in health management systems to ensure regulatory compliance
• Educate providers and interdepartmental teams on utilization processes to promote high-quality, cost-effective care
• Provide feedback to improve the authorization review process
• Perform other duties as assigned

Education / Certification

• Graduate from an accredited School of Nursing or Bachelor’s degree in Nursing with 2-4 years of related experience

L icensure

• RN California licensure required

Experience

• 2-3 years of clinical experience; UM a plus
• Clinical knowledge to analyze authorization requests and determine medical necessity
• Knowledge of Medicare and Medicaid regulations preferred
• Knowledge of utilization management processes preferred

Additional Qualities

• Critical thinking; ability to work independently; organizational and multitasking skills
• Microsoft Office Suite familiarity (Teams, OneNote, Excel, Word); tech-savvy

About the company

Pacer Group