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Job Title: Prior Authorization NurseJob Description

The Prior Authorization Nurse plays a crucial role in analyzing authorization requests to determine the medical necessity and appropriate level of care according to national standards and contractual requirements. The position involves collaborating with medical teams to enhance the quality and cost-effectiveness of medical care.

Responsibilities

+ Analyze prior authorization requests to determine medical necessity and appropriate level of care.

+ Provide recommendations to medical teams to promote quality and cost-effectiveness of care.

+ Conduct medical necessity and clinical reviews to ensure regulatory compliance.

+ Collaborate with healthcare providers and the authorization team for timely service reviews.

+ Coordinate with healthcare providers and interdepartmental teams to assess medical necessity.

+ Escalate prior authorization requests to Medical Directors when necessary.

+ Assist with service authorization requests for transfers or discharges to ensure timely transitions.

+ Document and maintain member clinical information in health management systems.

+ Educate providers and interdepartmental teams on utilization processes to promote quality care.

+ Provide feedback to improve the authorization review process.

+ Perform other duties as assigned and comply with all policies and standards.

Essential Skills

+ Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.

+ 2-4 years of related experience in clinical settings.

+ Current LPN - Licensed Practical Nurse State Licensure.

+ Clinical knowledge and ability to analyze authorization requests.

+ Familiarity with Medicare and Medicaid regulations.

+ Understanding of utilization management processes.

Additional Skills & Qualifications

+ Registered Nurse (RN) preferred.

+ Prior experience with clinical review preferred.

Work Environment

This is a 100% remote position with a collaborative team environment. Work hours are Monday to Friday, 8 AM to 5 PM, with rotating weekends. Initial training includes a four-week learning journey followed by preceptor training. Upon completion of training, the expectation is to process 15-17 authorizations per day.

Pay and Benefits

The pay range for this position is $36.00 - $36.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on May 2, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [email protected] (%[email protected]) for other accommodation options.