Clinical - Clinical Review Nurse - Prior Authorization - J00927
- Full-time
- Quick Apply
Job Description :
Job Title : Clinical Review Nurse Prior Authorization
Assignment Duration : 3 months (Possible Extension or conversion)
Work Location : Fully Remote Must reside in North Carolina
Schedule : Mon-Fri, 8 : 00 AM 5 : 00 PM EST
Work Type : Remote
Position Summary
The Clinical Review Nurse performs comprehensive prior authorization and clinical reviews to determine medical necessity and appropriate level of care in alignment with regulatory guidelines, clinical criteria, and member benefits. This role plays an essential part in ensuring timely, high-quality, and cost-effective healthcare services for members, with a strong focus on accuracy, efficiency, and collaboration with clinical and provider teams.
Key Responsibilities
Review prior authorization and clinical documentation to assess medical necessity in accordance with guidelines and criteria.
Collaborate with healthcare providers and internal authorization teams to ensure timely case resolution.
Escalate complex or non-clinical-criteria-meeting cases to Medical Directors for secondary review.
Support discharge and transfer planning through timely evaluation of service requests.
Accurately document and maintain all clinical review details within health management systems.
Provide education to internal teams and / or providers on utilization processes and clinical criteria.
Identify opportunities to enhance authorization review processes and recommend improvements.
Perform other related duties while adhering to organizational policies and compliance standards.
Required Qualifications
Education
Graduate of an accredited School of Nursing OR Bachelor s Degree in Nursing.
2 4 years of relevant clinical experience required.
Licensure
LPN (Licensed Practical Nurse) Active State Licensure required.
RN preferred (not required unless governed by state-specific regulations).
Preferred Experience & Skills
Minimum 2 years of experience performing prior authorization (PA) or inpatient (IP) clinical reviews within a health plan or insurance environment.
Knowledge of Medicare and Medicaid guidelines.
Understanding of utilization management processes.
Experience with NC State Criteria or InterQual Criteria (preferred).
Strong clinical judgment and ability to review medical documentation accurately.
Excellent communication skills and high level of professionalism.
Ability to work independently in a remote environment with minimal supervision.
Strong team collaboration mindset ( all hands on deck ).
Ability to meet productivity expectations (approx. 15 authorization reviews per day).
Work Environment
Fully Remote (NC-based).
Minimal team interaction outside of training and daily communication with supervisors / team leads.
Team-driven culture focused on collaboration, high output, and shared success.
Why This Role is Valuable
100% Remote role with stable weekday hours.
Opportunity to work on both Prior Authorization (PA) and Inpatient (IP) review cases.
Strong team support with a collaborative, high-performance environment.
Valuable experience gained in tailored plans and specialized authorization processes.
Candidate Expectations
Must be able to work the required schedule (Monday Friday, 8am 5pm EST).
Must be a strong team player with the ability to support high-volume workloads.
Must maintain accuracy, compliance, and productivity at all times.
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