Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Remote-TX (Sourced nationally - no CA or NY)

Assignment Duration: 1 year (Potential to extend and/or convert to FTE)

Work Schedule: 8AM-5PM their time zone, Monday-Friday, rotating weekends possible voluntary OT

Work Arrangement: Remote

Position Summary:

Reviewing PA requests, opening your auths, reviewing for medical necessity and then determining them.

Background & Context:

* Prior Authorization team for PA requests from non-contracted providers.

* Team consists of 30-32 employees; 3 smaller teams: Redirection, Clinical Review, and Single Case Agreement.

* All work closely together. This position is for the Clinical Review Team.

* Provider facing. Approvals and denials for prior auth.

Key Responsibilities:

* Reviewing PA requests, opening your auths, reviewing for medical necessity, determining approvals/denials.

* Team meetings may occur; CAMERA ON.

* Some phone time required to call providers for additional info or to inform of denial.

* Target productivity: 18-20 auths/day, 95% monthly productivity expected.

Qualification & Experience:

* Required: LVN/RN

* LVN/RN license MUST BE COMPACT

* 1+ year of authorization/prior auth nursing experience

* Proficient in Microsoft Office, multitasking across 3 screens/systems

* Disqualifiers: job hopping (contract roles excepted), most recent job must be related, illiteracy

* Preferred: Prior auth or managed care experience, work-from-home experience

Top 3 Must-Have Hard Skills (Ranked):

1. 
   

   Knowledge of Insurance Prior Authorization Processes and consistent policy adherence

   
   
2. 
   

   Ability to perform in fast-paced, high-volume environment

   
   
3. 
   

   Organizational/multitasking skills, computer literacy, ability to work independently