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 suitable level of care.

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

• Collaborate with healthcare providers and authorization teams to ensure prompt review of services and requests.

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

• Refer prior authorization requests to Medical Directors when appropriate.

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

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

• Educate providers and interdepartmental teams about utilization processes.

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

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

⛳️ Requirements

• A valid Texas RN license is required.

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

• 2–4 years of relevant experience.

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

• Preferred understanding of Medicare and Medicaid regulations.

• Preferred familiarity with utilization management processes.

🏝️ 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 incentives may be included in total compensation.

• Equal opportunity employment.

• Consideration for qualified applicants with arrest or conviction records in accordance with applicable law.