Clinical Review Nurse - Prior Authorization Various, NV

Clinical Review Nurse - Prior Authorization 

Various, NV 

All On-site

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Job Description

Location: Fully Remote – Prefer Candidates reside in NV, but cal reside elsewhere if they have a have NV RN License.

SHIFT: Training schedule is 3 weeks M-Fri 8AM-5PM PSt time ON CAMERA - NO TIME OFF

Work Schedule after training: M-Fri 8AM-5PM PST time

Duration: 3 months, Possibility to extend and/or convert to FTE

Start Date: 3/9/2026

Description: Analyzes all 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. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Responsibilities:

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 members transfer or discharge plans to ensure a timely discharge between levels of care and facilities

Collects, documents, and maintains all members 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

Performs other duties as assigned

Candidate Requirements

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.

Required: Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelors degree in Nursing and 2 – 4 years of related experience.

Preferred:

Required: MUST BE RN, Must Live in Nevada

MUST HAVE A NV LICENSE Preferred:

Years of experience required: MUST HAVE 2-4 years experience in health prior authorizations, case management, medical terminology/hipaa guidelines,

Disqualifiers: job hopping (want someone that will eventually be permanent at the client if the position comes available within department) PLEASE STATE IF CONTRACT ROLE.

Additional qualities to look for: Trucare, interqual

Top 3 must-have hard skills stack-ranked by importance

1 Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred/analytical and critical thinking skills/problem solving/attention to detail

2 Knowledge of Medicaid regulations preferred.

3 Knowledge of utilization management processes preferred.

Pay Rate: up to $44/hr. ***