Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization Work Location: Remote Assignment Duration: 6 months, Temp to perm Work Arrangement: Remote (Mountain/PST) 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. 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 LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required For Superior Health Plan: RN license required Additional Information: Candidates must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship will not be considered for any visas. Sub-contracting is not permitted. Contacting a hiring leader directly about a requisition or hiring need is not permitted. All contractors must sign a Temporary Worker Acknowledgement during background check acceptance.Education/Certification Required: Preferred:Licensure Required: RN Preferred: compact licensure will workYears of experience required: - 2 - 4 years of related experienceDisqualifiers: lack of Job stability (within 1 year or less), but please discern if worker has come off of temporary assignmentsAdditional qualities to look for: Candidates' integrity and ability to complete the cases assigned to them; Hard workersTop 3 must-have hard skills stack-ranked by importance 1 Ability to perform real time review of outpatient cases2 Strong understanding of medical necessity guidelines, such as InterQual3 Skilled at interpreting clinical documentation and determining appropriate levels of care

Created: 2026-03-10