Clinical Review Nurse - Prior Authorization - J00927 Tues – Sat Shift

Location: 100% Remote, PST and CST candidates preferred,
(No CA and NY candidates please)

SHIFT: Tues Sat

Shifts depend on what the team needs.
Possible shifts in both PST and CST
7am 4pm
8am 5pm
9am 6pm
10pm 7pm

Duration: 12 months, unsure of extension at this time.

Potential start date: 10/26/2026

Description: Job Profile Summary: Routinely reviews 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. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Candidate Requirements
Education/Certification	Required: Requires Graduate from an Accredited School of Nursing or Bachelors degree in Nursing and 2-4 years of experience			Preferred:
Licensure	Required: Required: RN- Registered Nurse/ LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria			Preferred: NV or Compact RN license
Years of experience required: Nice to haves: 2-4 years of related experience. Prior PA experience required, experience in InterQual/ Milliman, One Note, knowledge of Utilization Management (policies/regulations), at least 1 candidate must have NV license. Disqualifiers: California and NY candidates Additional qualities to look for: Team player, flexible
Top 3 must-have hard skills stack-ranked by importance		1	Prior preservice or prior authorization in Utilization Management department experience required. There is no exception to this required minimum skills experience.
		2	Experience in InterQual or Milliman
		3	Organizational skills, detailed oriented, able to work independently and make decision in fast paced role, disciplined, technology dexterity, change management minded, Customer centricity minded.