Remote Clinical Prior Authorization Reviewer

Actalent; Portland (OR); Remote; USD 48,000 - 55,000; Full time

Benefits offered by this job

Medical, dental & vision

401(k) plan

Life Insurance

Short/Long-term disability

Health Savings Account (HSA)

Transportation benefits

Employee Assistance Program

Time Off / PTO

Job summary

Actalent seeks a Clinical Prior Authorization Reviewer to assess medical necessity and determine the appropriate level of care for requests. You will support complex cases with evidence-based recommendations and collaborate with the care team to ensure compliant, cost-effective decisions.

The role emphasizes utilization management, adherence to InterQual/Milliman criteria, and timely documentation in One Note within a fully remote, contract-based environment across Pacific/central time zones.

Qualifications

• Experience performing clinical review of prior authorization requests.
• Experience using InterQual and/or Milliman clinical criteria for medical necessity determinations.
• Preference for 24 years of related clinical review or utilization management experience.

Responsibilities

• Review prior authorization requests on a routine basis to assess medical necessity of services.
• Determine the appropriate level of care for requested services in accordance with national standards.
• Verify that requested services comply with contractual requirements and member benefits.
• Conduct clinical reviews of more complex authorization requests and identify issues or risks.
• Provide clear, well-supported recommendations to the medical team for complex cases.
• Promote quality and cost-effective medical care through utilization review and decision-making.
• Apply utilization management policies and regulations consistently.
• Document clinical review findings and recommendations accurately using required systems such as One Note.
• Collaborate with clinical and non-clinical team members to support efficient prior authorization processes.
• Maintain up-to-date knowledge of InterQual and Milliman criteria and organizational policies.

Skills

Clinical review

Prior authorization processes

InterQual/Milliman criteria

Utilization management

Team collaboration

Tools

One Note

Job description

Actalent seeks a Clinical Prior Authorization Reviewer to assess medical necessity and determine the appropriate level of care for requests. You will support complex cases with evidence-based recommendations and collaborate with the care team to ensure compliant, cost-effective decisions.

The role emphasizes utilization management, adherence to InterQual/Milliman criteria, and timely documentation in One Note within a fully remote, contract-based environment across Pacific/central time zones.