Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse- Prior Authorization Work Location: Remote, any time zone but must work CST hours Assignment Duration: 03 Months Possible to extend Work Schedule: Monday- Friday 10a-7pm, rotating weekends Training M-F 8-5 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: CMS TAT ruling, Backfill for 2 prior temps, this is a late shift position working Monday- Friday 10a-7pm, rotating weekends to meet the regulatory TAT requirements set forth by the Center of Medicare Services Ruling effective 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 Education/Certification Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing Preferred: Licensure Required: RN license required- Texas or Compact Preferred: Years of experience required: 1+ years- Nursing Disqualifiers: If unable to work 10a-7p and rotation weekends- No compact license if living outside of Texas Additional qualities to look for: Top 3 must-have hard skills stack-ranked by importance 1 Computer skills 2 Fast paced environment 3 Critical thinking

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