Prior Authorization Clinical Review Nurse - CST (165191)

Clinical Review Nurse – Prior Authorization (Remote)
Pay Rate: $42/hour
Schedule: Monday–Friday, 8:00 AM – 5:00 PM (CST hours)
Location: Fully Remote (must hold compact licensure)
Contract: 6-month contract with potential to extend or convert
Target Start Date: February 9 (Tentative)

Job Summary

A-Line Staffing is seeking an experienced Clinical Review Nurse – Prior Authorization to support a Medicaid line of business in a fully remote capacity. This role is responsible for reviewing outpatient prior authorization requests and determining medical necessity and appropriate levels of care using established clinical criteria, regulatory guidelines, and member benefit coverage. The nurse will collaborate closely with medical directors, providers, therapists, and internal authorization teams to ensure timely, compliant, and cost-effective care decisions.

Key Responsibilities

• Perform medical necessity and clinical reviews of prior authorization requests in accordance with national standards, regulatory guidelines, and utilization management criteria
• Review outpatient service requests using InterQual to determine medical appropriateness of care
• Coordinate with healthcare providers and internal teams to ensure timely authorization decisions
• Collaborate with medical directors and escalate cases as appropriate to determine level of care
• Support transfer and discharge planning to ensure continuity of care across facilities and levels of care
• Collect, document, and maintain accurate clinical information in health management systems
• Provide education to providers and internal teams on utilization management and authorization processes
• Identify opportunities to improve authorization workflows and processes
• Maintain compliance with all policies, procedures, and regulatory requirements
• Perform other duties as assigned

Required Qualifications

• Graduate of an accredited school of nursing or Bachelor’s degree in Nursing
• 2–4 years of related utilization management experience
• Active LPN or RN license (must be able to legally practice in Louisiana)
• Experience reviewing prior authorization or utilization management cases
• Required knowledge of Medicare and Medicaid regulations
• Required knowledge of utilization management processes
• Experience working with InterQual or similar medical necessity criteria

Preferred Qualifications

• Strong clinical knowledge with the ability to analyze authorization requests and determine medical necessity
• Experience supporting Medicaid populations
• Prior authorization experience in an outpatient setting

Additional Skills & Attributes

• Comfortable with provider outreach via phone and email; professional phone etiquette required
• Strong written communication and documentation skills
• Highly organized, accountable, and detail-oriented
• Self-starter with the ability to work independently in a remote environment
• Collaborative team player with strong clinical judgment

INDSV

Pay: $42.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Experience:

• Utilization management: 2 years (Required)

Work Location: Remote

Salary : $42