Position Title: Clinical Review Nurse – Prior Authorization
Work Location: Fully Remote – MST/PST only
Assignment Duration: 3 months
Work Schedule:

• Training: 3 weeks, Monday–Friday, 8AM–5PM AZ time, on camera, no time off

• Ongoing: Monday–Friday, 8AM–5PM AZ time
  Work Arrangement: Remote

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:
Prior Authorization Clinical Review Nurse role supporting health plan utilization management activities. May call a provider for more information but will not be in contact with members.

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:

• 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

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

• LPN, RN, or BSN

• 2–4 years experience in health authorizations, medical terminology/hipaa guidelines

• Trucare and Microsoft applications

Working Conditions & Physical Demands (If Applicable):

• Fully remote role aligned to Arizona time zone

• May call providers for additional information but no member-facing interaction

 
 
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: $ 35.00/hr.