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We are seeking an experienced Clinical Review Nurse – Prior Authorization. In this role, you will perform medical necessity and clinical reviews of authorization requests, ensuring members receive timely and appropriate care in accordance with regulatory guidelines.
Key Responsibilities
Conduct medical necessity and clinical reviews for prior authorization requests.
Collaborate with healthcare providers and the authorization team to support timely decisions.
Escalate cases to Medical Directors when additional review is required.
Support member transitions of care, including transfers and discharges.
Document all clinical information in health management systems to ensure compliance.
Provide education to providers and teams on utilization processes.
Recommend process improvements to enhance the authorization review workflow.
Schedule
Tuesday – Saturday, 8:00 AM – 5:00 PM EST
No overtime expectations.
Must be able to work 1 weekend per month and select holidays.
Required Qualifications
Active LPN or RN license (WA compact accepted or Oregon license)
Minimum 2 years of prior authorization or inpatient authorization review experience (insurance setting preferred).
Strong ability to work independently and as part of a collaborative team.
Comfortable adapting to flexible schedules and Medicaid plan requirements.
Preferred Qualifications
RN degree (preferred over LPN).
Prior experience with WA / OR Medicaid Prior Authorization reviews.
Positive attitude, willingness to learn, and ability to handle up to 20 authorization reviews per day.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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