** Candidate who are local from California will be accepted**
Job Title: Clinical Review Nurse - Prior Authorization
Duration: 12 months Contract (Possibility to convert to FTE if position opens)
Desired Start Date/End Date: 10/15/2025 - 10/14/2026
Location: Remote- California
Shift Type: 8-5 PM PST. NO OT, Holidays, or weekends , Training 8-5PM PST – 4–6-week course – No Time Off – Camera On
Payrate: 41-43$/hr
Job Duties:
• Performs 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
Years of experience required:
• 2-3 years of clinical experience.
• UM a plus, 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.
Disqualifiers: Not having a CA RN license, No long pauses in recent work history,
Education/Certification Required:
Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.
Licensure
Required: RN CA licensure required
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