Clinical Review Nurse – Prior Authorization

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Evaluate all prior authorization requests to assess medical necessity and the appropriate level of care.

• Offer recommendations to the relevant medical team to enhance the quality and cost-effectiveness of medical care.

• Conduct medical necessity and clinical evaluations of authorization requests in line with regulatory guidelines and criteria.

• Collaborate with healthcare providers and the authorization team to guarantee timely reviews of services and requests.

• Coordinate with healthcare providers and interdepartmental teams to evaluate the medical necessity of care.

• Elevate prior authorization requests to Medical Directors when necessary.

• Assist with service authorization requests related to member transfer or discharge plans.

• Gather, document, and maintain member clinical information within health management systems.

• Educate providers and interdepartmental teams on utilization processes.

• Provide insights on potential improvements to the authorization review process.

• Carry out additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Graduate from an accredited nursing school or hold a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience.

• LPN - Licensed Practical Nurse - State Licensure is required.

• Preferably possess clinical knowledge and the ability to analyze authorization requests and determine the medical necessity of services.

• Preferably knowledgeable about Medicare and Medicaid regulations.

• Preferably familiar with utilization management processes.

• Availability to work Monday–Friday, from 8 am to 5 pm.

• Applicants must be able to work remotely from any location within the state of Missouri.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off, plus holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.