New

Clinical Review Nurse - Prior Authorization

Spectraforce Technologies
United States, Arizona, Phoenix
Dec 30, 2025
Position Title: Clinical Review Nurse - Prior Authorization Work Location: Fully Remote - candidates can reside anywhere in the US but will be working AZ time. They need to have AZ license or compact license (with compact license, needs to reside in compact state) Assignment Duration: 3 months Work Schedule: Training: 3 weeks, Monday-Friday, 8AM-5PM AZ time, on camera, no time off Ongoing: Monday-Friday, 8AM-5PM AZ time Work Arrangement: Remote Position Summary: 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. Background & Context: Prior Authorization Clinical Review Nurse role supporting health plan utilization management activities. May call a provider for more information but will not be in contact with members. Key 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 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 Performs other duties as assigned Complies with all policies and standards Qualification & Experience: 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 Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience LPN, RN, or BSN 2-4 years experience in health authorizations, medical terminology/hipaa guidelines Trucare and Microsoft applications Working Conditions & Physical Demands (If Applicable): Fully remote role aligned to Arizona time zone May call providers for additional information but no member-facing interaction