Position Title: Clinical Review Nurse- Prior Authorization
Work Location: Remote, any time zone but must work CST hours
Assignment Duration: 03 Months Possible to extend
Work Schedule: Monday- Friday 10a-7pm, rotating weekends Training M-F 8-5
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:

CMS TAT ruling, Backfill for 2 prior temps, this is a late shift position working Monday- Friday 10a-7pm, rotating weekends to meet the regulatory TAT requirements set forth by the Center of Medicare Services Ruling effective 1/1/26.

---

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

Education/Certification	Required: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing			Preferred:
Licensure	Required: RN license required- Texas or Compact			Preferred:
Years of experience required: 1+  years- Nursing   Disqualifiers: If unable to work 10a-7p and rotation weekends- No compact license if living outside of Texas   Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance		1	Computer skills
		2	Fast paced environment
		3	Critical thinking

 

At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's starting pay is: $39.00/hr.