Clinical Review Nurse

Job Title : Clinical Review Nurse - Prior Authorization

Location : Remote (this position is looking for east coast nurses who would be willing to help out the PST team on a remote short term contract)

Contract Duration : 3 months

Schedule : Monday-Friday, 8 : 00 AM-5 : 00 PM PST (occasional weekend / holiday rotation)

Position Summary

The Clinical Review Nurse will conduct medical necessity reviews for prior authorization and inpatient service requests, ensuring compliance with Medicaid guidelines and promoting high-quality, cost-effective care. This role supports the Trillium Medicaid Plan and operates within a collaborative but independently driven team.

Key Responsibilities

Review prior authorization (PA) and inpatient (IP) requests for medical necessity using national standards and regulatory criteria

Escalate complex cases to Medical Directors for further evaluation

Coordinate with providers and internal teams to support timely discharge planning and transitions between care levels

Document clinical decisions and maintain accurate records in health management systems

Educate providers and internal teams on utilization processes and coverage policies

Identify opportunities to improve authorization workflows and member experience

Maintain compliance with OSHA, HIPAA, and Centene standards

Complete up to 20 authorization reviews per day

Participate in team huddles and contribute to a supportive, all-hands-on-deck culture

Required Qualifications

Active RN or LPN license

Minimum 2 years of prior authorization or inpatient review experience with a health plan or insurance company

Strong clinical judgment and understanding of medical necessity criteria

Familiarity with Medicaid regulations and utilization management processes

Ability to work independently while contributing to a collaborative team

Willingness to work one weekend per month and occasional holidays

Preferred Qualifications

Experience with Trillium Plan or Oregon Medicaid

Positive attitude and eagerness to learn

Proficiency with EMR systems and clinical documentation platforms

Team Culture & Work Environment

Friendly, welcoming team that values collaboration and independence

Remote-first environment with structured onboarding and training

"One for all, all for one" mindset - everyone contributes to shared goals

No possibility of extension or conversion; focused short-term engagement

Pay and Benefits

The pay range for this position is $35.00 - $40.00 / hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following :

• Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off / Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Nov 11, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.