Clinical UR Nurse (Prior Authorization) - Remote

Founded in 1998, BCforward is a Black-owned global leader in workforce management and digital product delivery solutions, headquartered in Indianapolis, IN. With a worldwide team of over 6,000 consultants, BCforward is dedicated to empowering human potential through its core values: People-Centricity, Excellence, and Diversity. As an industry pioneer, BCforward provides a best-in-class workplace, fostering a culture of accountability, innovation, and optimism. Committed to equal opportunity employment, the company champions diversity and inclusion, striving to create a positive impact for its clients, employees, and communities.

Clinical Review Nurse - Prior Authorization - J00927 BC Forward is looking for Clinical UR Nurse (Prior Authorization) - Remote Position: Clinical UR Nurse (Prior Authorization) - Remote Location: Remote - Indiana Anticipated Start date : 09/01 Duration: 3 months Contract to Hire Shift Schedule: Monday-Friday, 8:00 AM - 5:00 PM EST | Occasional overtime (rare) | On-call rotation required Pay Rate: $42.82/hr on W2 Need: Graduate of an accredited nursing program (Diploma, ADN, or BSN) with 2-4 years of clinical experience in acute care, case management, or utilization review; current, unrestricted LPN or RN license in Indiana or a compact state. Job Description: Position Purpose The Clinical Utilization Review Nurse performs comprehensive clinical evaluations of prior authorization requests to determine medical necessity, appropriate level of care, and alignment with national standards, contractual obligations, and member benefit coverage. This role supports high-quality, cost-effective healthcare by providing evidence-based recommendations to internal medical teams and collaborating with providers to ensure timely access to care. The position operates remotely and plays a critical role in compliance with regulatory requirements, including those set forth by CMS.

Conduct thorough medical necessity and clinical reviews of prior authorization requests for outpatient, ambulatory services, procedures, and durable medical equipment (DME), using evidence-based criteria such as InterQual (preferred). Evaluate requests in accordance with federal and state regulations, payer contracts, clinical guidelines, and member-specific benefits. Collaborate directly with healthcare providers via phone (outbound and inbound) to gather clinical information, clarify documentation, and support timely decision-making. Coordinate with interdisciplinary teams, including authorization specialists and medical directors, to assess appropriateness of care and facilitate seamless care transitions. Escalate complex or non-routine cases to Medical Directors when clinical judgment or exceptions are required. Support discharge planning and patient transfers between levels of care or facilities by reviewing service requests and ensuring continuity. Accurately collect, document, and maintain member clinical data in health management systems, ensuring compliance with HIPAA, NCQA, CMS, and other regulatory standards. Assist in educating providers and internal teams on utilization management processes, policy updates, and best practices to improve quality and efficiency. Identify and provide feedback on opportunities to optimize the prior authorization process, reduce delays, and enhance member and provider experience. Participate in on-call rotations with team members to support after-hours coverage as needed. Perform other duties as assigned. Maintain strict adherence to company policies, procedures, and ethical standards.