Clinical Review Nurse – Prior Authorization

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

📋 Description

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

• Conduct medical necessity and clinical reviews in alignment with regulatory guidelines and criteria.

• Collaborate with healthcare providers and authorization teams to ensure timely service and request reviews.

• Coordinate with healthcare providers and interdepartmental teams to evaluate members’ medical necessity for care.

• Elevate prior authorization requests to Medical Directors when necessary.

• Assist in processing member transfer or discharge service authorization requests.

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

• Educate providers and interdepartmental teams regarding utilization processes.

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

• Adhere to all policies and standards while performing additional assigned responsibilities.

⛳️ Requirements

• Graduate from an Accredited School of Nursing or possess a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience.

• Texas RN license is mandatory.

• Preferred clinical knowledge and ability to analyze authorization requests to ascertain medical necessity of services.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Additional incentive options may be included in overall compensation.