Job Description

Position Title: Clinical Review Nurse - Prior Authorization

Location: Remote EST

Duration: 12 Months

Schedule: 8am-5pm Est zone. OT may be required but will have opportunities based on business needs. News Years Day, Thanksgiving Day and Christmas Day guaranteed holidays and off. Other holidays, based on business needs, may be asked to work. We have a rotating weekend schedule typically every 5 weeks and once training is finished, you will work Sat and Sun 8 hours each day.2 days during the week will offset that weekend expectation that you have the choice of choosing off.



Day-to-Day Responsibilities:

• Address email correspondence and review Teams messages for updates and important information.
• Review calendar to prepare for important meetings, huddles, or training sessions.
• Conduct up to 10-15 calls daily with providers to review authorization requests and follow up on cases.
• Complete and maintain accurate documentation and logs in the clinical systems.
• Adhere to performance expectations such as timely reviews, case referrals, and meeting quality standards.

• Productivity Standard: Maintain a minimum of 15 reviews per day.
• Referral Accuracy: Appropriately refer cases for secondary review, ensuring benchmarks and quality audits are met (RN to MD Referral Rate).
• TAT Performance: Maintain 100% Turnaround Time (TAT) performance.
• Quality: Ensure monthly quality reviews are 95%.
• Criteria Application: Demonstrate comprehension of criteria application (IQ/IQC/MCG) and pass the annual IRR.
• Documentation: Demonstrate understanding of clinical documentation systems and maintain accurate records.
• Excel Skills: Basic proficiency in Excel.
• Communication: Maintain professional and courteous communication at all times.

• Prior Experience :
  • Prior experience in Prior Authorization (PA) or Utilization Management (UM) is required .
  • Experience with InterQual or Milliman guidelines is preferred.
  • Previous roles should include independent, fast-paced, detail-oriented work with heavy documentation.
  • Knowledge of clinical policies and regulations such as Medicare and Medicaid is highly valued.
• Previous Job Titles :
  • Clinical Review Nurse
  • Pre-Service Nurse
  • Prior Authorization Nurse
  • Charge Nurse
  • Director of Nursing
  • Leadership Roles in Nursing

• Required Skills :

  1. Prior experience in a Preservice or Prior Authorization role in a Utilization Management department.
  2. Experience with InterQual or Milliman.
  3. Strong organizational skills, attention to detail, and the ability to work independently in a fast-paced environment.
  4. Technological proficiency and adaptability, with a customer-centric approach.

• Preferred Skills :

  1. Clinical knowledge with the ability to analyze authorization requests and assess medical necessity.
  2. Knowledge of Medicare and Medicaid regulations.
  3. Familiarity with Utilization Management processes.

• Required Education : Graduate from an accredited School of Nursing or a Bachelor's degree in Nursing.

• Experience : 2-4 years of relevant experience in a clinical or utilization management setting.

• Preferred Education : N/A

• Required Certifications :

  • Licensed Practical Nurse (LPN) State Licensure required.

• Software Skills :

  • Experience with InterQual and Milliman.
  • Proficient in Microsoft Outlook and basic internet navigation.

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