Position Title: Clinical Review Nurse – Prior Authorization
Work Location: Remote–sourced nationally
Assignment Duration: 7 Months Contract to Hire
Work Schedule: Monday – Friday (8 hours) (Can be EST (highly preferred), CST (second preference).

Position Summary:

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.

Key Responsibilities:

• Reviewing authorization requests

• Utilizing evidence-based criteria and making a medically necessary determination.

• Outreach calls to providers to request additional details if applicable.

• They will not be completing any calls to members.

Qualification & Experience:

• ICU, Medical Surgical background, bedside experience (Home health nurses)

• Utilization Review (Prior Authorization)

• Acute Care

• Medicare experience ( Utilization Management with Medicare)

• CCM Certification

• ACLS Certification

• Bachelor’s with RN or RN without Bachelors is okay too

• TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems

• RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay)

  Internal/External Groups with which the Candidate will interface:
  Required Skills/Experience:				Preferred Skills/ Experience:
  1.	ICU, Medical Surgical background, bedside experience (Home health nurses)			1.	Medicare experience ( Utilization Management with Medicare)
  2.	Utilization Review (Prior Authorization)			2.	CCM Certification
  3.	Acute Care			3.	ACLS Certification
  Education Requirement:		Bachelor’s with RN or RN without Bachelors is okay too		Education Preferred:
  Software Skills Required:		TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems
  Required Certifications:		RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay)   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.		Required Testing:		n/a

 

 


At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $36.00/hr.