Clinical Review Nurse – Prior Authorization

Clinical Review Nurse – Prior Authorization (Remote CST Hours)

Location: Remote
Schedule: Monday–Friday, 10:00 AM–7:00 PM CST with rotating weekends
Training Schedule: Monday–Friday, 8:00 AM–5:00 PM CST
Pay Rate: $40.00–$43.00/hour
Employment Type: W2 Contract – 3 Month Assignment with potential for extension

We are hiring a Clinical Review Nurse to support prior authorization and utilization review operations in a fully remote setting. This role focuses on reviewing authorization requests, evaluating medical necessity, coordinating with providers, and ensuring timely approvals and continuity of care for members. Candidates must be comfortable working CST hours regardless of time zone.

Job Responsibilities

• Perform medical necessity and clinical reviews of prior authorization requests using regulatory guidelines and established clinical criteria
• Review documentation to determine medical appropriateness of requested services and care
• Coordinate with healthcare providers and internal authorization teams to ensure timely processing of requests
• Escalate cases to Medical Directors when additional clinical review is required
• Support transfer and discharge authorization requests to help facilitate timely transitions between levels of care and facilities
• Collect, document, and maintain member clinical information within health management systems
• Assist with educating providers and internal teams on utilization management and authorization processes
• Identify and communicate opportunities to improve authorization workflows and review processes
• Maintain compliance with company policies, clinical standards, and regulatory requirements
• Perform additional duties as assigned

Required Qualifications

• Graduate of an accredited School of Nursing or Bachelor’s degree in Nursing
• Active RN license required (Texas RN license or Compact RN license)
• Multiple years of directly related prior authorization, utilization review, or clinical review experience
• Experience reviewing medical necessity and authorization requests
• Strong understanding of utilization management processes and clinical documentation
• Ability to work independently in a remote environment
• Strong communication and organizational skills

Preferred Backgrounds

Candidates with experience in the following areas are encouraged to apply:

• Prior Authorization Nurse
• Utilization Review Nurse
• Case Management Nurse
• Clinical Review Nurse
• Concurrent Review Nurse
• Managed Care Nurse
• UM Nurse
• Appeals and Grievances
• Health Plan or Insurance Experience
• Hospital Case Management
• Discharge Planning
• Care Coordination

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