Clinical Review Nurse (Remote)

Actalent; Dallas (TX); Remoto; USD 48.000 - 55.000; Tempo pieno

Descrizione del lavoro

Actalent is seeking a Clinical Prior Authorization Reviewer to join our remote team supporting Dallas, TX operations. This contract role focuses on evaluating prior authorization requests for medical necessity and appropriate level of care using InterQual and Milliman criteria.

You will collaborate with clinical and non-clinical colleagues, document findings in One Note, and stay current with utilization management standards to ensure compliant and timely reviews.

Competenze

• 24 years of related experience in clinical review or prior authorization.
• Experience with prior authorization processes.
• Hands-on experience using InterQual criteria for clinical review.
• Hands-on experience using Milliman (MCG) guidelines for clinical review.
• Knowledge of utilization management policies, regulations, and standard practices.
• Ability to assess medical necessity and appropriate level of care.
• Strong analytical and critical thinking skills.

Mansioni

• Review prior authorization requests on a routine basis to determine medical necessity of services and appropriate level of care.
• Evaluate requests in accordance with national clinical standards, contractual requirements, and individual member benefit coverage.
• Assess more complex authorization cases and identify situations that require additional clinical consideration.
• Develop and present clear, well-supported recommendations to the medical team for complex authorization requests.
• Support quality and cost-effective medical care by applying utilization management policies, regulations, and guidelines.
• Use tools such as InterQual and Milliman to conduct clinical reviews and inform authorization decisions.
• Document clinical review findings and recommendations accurately and consistently, including use of systems such as One Note.
• Collaborate with clinical and non-clinical team members to ensure timely and appropriate authorization decisions.
• Stay current with utilization management standards, policies, and regulations to maintain compliance in all reviews.

Conoscenze

Clinical review

Analytical thinking

Utilization management

Team collaboration

Time management

Strumenti

InterQual

Milliman (MCG)

Descrizione del lavoro

Job Title: Clinical Prior Authorization Reviewer

Job Description

This role focuses on reviewing prior authorization requests to determine medical necessity and appropriate level of care in alignment with national standards, contractual requirements, and member benefit coverage. The position involves assessing routine and complex authorization requests, supporting utilization management processes, and providing recommendations that promote high-quality and cost-effective medical care.

Responsibilities

• Review prior authorization requests on a routine basis to determine medical necessity of services and appropriate level of care.


• Evaluate requests in accordance with national clinical standards, contractual requirements, and individual member benefit coverage.


• Assess more complex authorization cases and identify situations that require additional clinical consideration.


• Develop and present clear, well-supported recommendations to the medical team for complex authorization requests.


• Support quality and cost-effective medical care by applying utilization management policies, regulations, and guidelines.


• Use tools such as InterQual and Milliman to conduct clinical reviews and inform authorization decisions.


• Document clinical review findings and recommendations accurately and consistently, including use of systems such as One Note.


• Collaborate with clinical and non-clinical team members to ensure timely and appropriate authorization decisions.


• Stay current with utilization management standards, policies, and regulations to maintain compliance in all reviews.

Qualifications

• 24 years of related experience in clinical review or prior authorization.


• Demonstrated prior experience with prior authorization processes.


• Hands-on experience using InterQual criteria for clinical review.


• Hands-on experience using Milliman (MCG) guidelines for clinical review.


• Knowledge of utilization management policies, regulations, and standard practices.


• Ability to assess medical necessity and appropriate level of care based on established criteria and benefit coverage.


• Strong analytical and critical thinking skills for evaluating routine and complex clinical cases.

Work Environment

This position operates within a structured clinical review and utilization management environment that supports both Pacific and Central time zones. The role follows a Tuesday through Saturday schedule, with shifts assigned based on team needs. Potential shifts include 7:00 a.m. to 4:00 p.m., 8:00 a.m. to 5:00 p.m., and 9:00 a.m. to 6:00 p.m. Work is performed using clinical criteria tools such as InterQual and Milliman, along with documentation platforms like One Note, in a professional setting focused on accurate, timely review of medical services and coordination with medical teams.

Job Type & Location

This is a Contract position based out of Dallas, TX.

Pay and Benefits

The pay range for this position is $35.00 - $40.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

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 Oct 15, 2026.

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 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service.

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 process due to a disability, please email [e-mail] for other accommodation options.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.