Job Description

Job Description:

Job Title: Clinical Review Nurse- Prior Authorization

Duration: 6 months (Possible Extension)

Location: Remote

Shift: Day 5x8-Hour (08:00AM - 05:00PM) EST

About the Role:

Seeking Clinical Review Nurses Prior Authorization to support its growing Prior Authorization (PA) team. In this role, you will review prior authorization requests for the Medicaid line of business, helping to reduce backlog and ensure timely care delivery to members. This is a collaborative and highly supportive virtual team environment.

Key Responsibilities:

• Review prior authorization requests for medical necessity, completeness, and accuracy in alignment with established clinical guidelines.

• Document determinations with a focus on quality and regulatory compliance.

• Toggle between multiple clinical systems and databases with efficiency.

• Communicate effectively with the internal PA team via email and virtual huddles.

• Process up to 18 authorization requests daily, meeting timeliness and quality metrics.

• Maintain a positive, team-oriented approach in a remote work setting.

Required Qualifications:

• Graduate from an accredited School of Nursing or Bachelor's degree in Nursing.

• Active, unrestricted Nursing Licensure (Registered Nurse RN).

• 2 4 years of recent and relevant clinical nursing experience.

• Prior experience in care management, clinical review, prior authorization, or utilization management.

• Strong computer proficiency and the ability to work across multiple systems.

• Exceptional written communication and documentation skills.

Preferred Experience:

• Previous work as a Prior Authorization Nurse, Appeals Nurse, Medical Review Nurse, or Quality Assurance Nurse.

• Experience with Medicaid or managed care environments.

• High attention to detail and a strong sense of accountability.

Performance Expectations:

• Quality documentation and timely processing of prior auth requests.

• Daily productivity target: 18 prior authorizations reviewed.

• Positive team collaboration and communication.

• Flexibility to adjust work schedule based on team needs.

Team & Culture Highlights:

• Biweekly virtual huddles and ongoing email collaboration.

• Strong team support and knowledge sharing.

• Opportunity to work independently while being part of a close-knit team.

Additional Information:

• This is a remote role; candidates must reside in Ohio and be available to work on Eastern Time.

• No overtime or weekend work is expected.

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