Position Title: Clinical Review Nurse - Prior Authorization
Work Location: Arizona (must be independently licensed and living in AZ)
Assignment Duration: 5 Months
Work Schedule: Standard hours (8-5), M-F, no OT required
Work Arrangement: Remote to specific state, nationally sourced, or specific time zone? Arizona (must be independently licensed and living in AZ)

Position Summary:

• Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Background & Context:

• This a backfill for UM specifically for med record review and to ensure compliance of CMS final rule of 7 day TAT starting 1/1/26.

Key Responsibilities:

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

• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care

• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member

• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care

• Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities

• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines

• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members

• Provides feedback on opportunities to improve the authorization review process for members

• Performs other duties as assigned

• Complies with all policies and standards

Qualification & Experience:

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.

• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

• Knowledge of Medicare and Medicaid regulations preferred.

• Knowledge of utilization management processes preferred.

License/Certification:

• LPN - Licensed Practical Nurse - State Licensure required

• For Health Net of California: RN license required

• For Superior Health Plan: RN license required

Candidate Requirements:

• Education/Certification Required: graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience

• Licensure Required: LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure)

• Years of experience required: they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review

Disqualifiers / Additional qualities:

• Disqualifiers: not independently licensed in AZ, not living in AZ

• Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review

• Top 3 must-have hard skills stack-ranked by importance:

  1. Behavioral health clinical review skills

  2. Computer proficiency

• Ability to multi-task and remain organized
  
  ?

  Education/Certification	Required: graduate of an accredited school of nursing or a BA degree and 2-4 years of related experience			Preferred:
  Licensure	Required: LCSW, LMHC, LPC, LMFT, LMHP, or RN (state OR compact state licensure)			Preferred:
  Years of experience required: they should have at least 2 years in the behavioral health field; it would be a bonus if they also had some experience in utilization review   Disqualifiers: not independently licensed in AZ, not living in AZ   Additional qualities to look for: expertise reviewing BH medical charts, treatment plans, any experience in BH utilization review
  Top 3 must-have hard skills stack-ranked by importance		1	Behavioral health clinical review skills
  		2	Computer proficiency
  		3	Ability to multi-task and remain organized

 
 
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: $ 37.00/hr.