Prior Authorization Nurse - Clinical Review

Job Title: Clinical Review Nurse – Prior Authorization Duration: 12 months Contract. Desired Start Date/End Date: 6/2/2025 - 5/29/2026 Location: Remote. (MST time would be preferred) Shift Type: Mon to Thu-Sat 7am-6pm or Wed-Sat 7am-6pm (Saturday a must)

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. Performing clinical reviews for our non-par authorization requests. 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