Clinical Review Nurse - Prior Authorization

Spectraforce Technologies

United States, North Carolina, Raleigh

500 West Peace Street (Show on map)

Apr 29, 2025

Title: Clinical Review Nurse- Prior Authorization

Location: Remote

Duration: 12 Months

Shift: 8a-5p CST M-F rotating weekends

Job Description:

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.

Education/Experience:

Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

Knowledge of Medicare and Medicaid regulations preferred.

Knowledge of utilization management processes preferred.

License/Certification:

LPN - Licensed Practical Nurse - State Licensure requiredPerforms medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

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

Performs other duties as assigned

Complies with all policies and standards

Candidate Requirements
Education/Certification	Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.	Preferred:
Licensure	Required: i.e. RN	Preferred:
Years of experience required	Must haves: 6 Months or more of RN experience. Nice to haves: Performance indicators: Hitting 15-17 auths per day Best vs. average:
Top 3 must-have hard skills	1	Microsoft
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