Clinical - Clinical Review Nurse - Prior Authorization - J00927

Job Description:

Job Title: Clinical Review Nurse - Prior Authorization"

Location: Remote

Duration: 3 months (Contract)

Schedule: 8am-5pm EST - Mon-Fri

About the Role

We are seeking an experienced Clinical Review Nurse Prior Authorization to join our NC Tailored Plans team (Trillium/Partners). The nurse will perform medical necessity and clinical reviews of authorization requests to ensure members receive timely, medically appropriate care while maintaining compliance with state and federal regulations. This position is fully remote, supporting WA and OR Medicaid plans.

Key Responsibilities

• Perform medical necessity and clinical reviews for prior authorization and inpatient authorization requests.

• Collaborate with providers, healthcare teams, and medical directors to determine appropriate care.

• Ensure timely processing of authorization requests in accordance with regulatory guidelines.

• Document all member clinical information in health management systems accurately and compliantly.

• Assist with discharge planning and care transitions between levels of care/facilities.

• Educate providers and internal teams on utilization processes to promote cost-effective, high-quality care.

• Support improvements in authorization review processes and team workflows.

• Meet daily case review productivity expectations (up to 20 authorization reviews/day).

Required Qualifications

• Active RN or LPN license (WA compact license acceptable; OR license required or willingness to obtain).

• Minimum 2 years of prior authorization experience with an insurance company or health plan.

• Strong clinical review skills, with the ability to evaluate medical necessity and escalate appropriately.

• Excellent communication, organizational, and critical thinking skills.

• Ability to work independently and as part of a collaborative team.

Preferred Qualifications

• Experience with Medicaid Prior Authorization (WA/OR).

• Prior experience with inpatient (IP) authorization reviews.

• Positive, adaptable attitude and willingness to learn.