• Clinical Review Nurse - Prior Authorization

    Actalent (West Des Moines, IA)


    Prior Authorization Nurse

    Job Description

    This role involves analyzing prior authorization requests to determine the medical necessity of services and the appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. The position provides recommendations to the medical team to ensure quality and cost-effectiveness of medical care.

    Responsibilities

    + Perform medical necessity and clinical reviews of authorization requests to determine the appropriateness of care in accordance with regulatory guidelines and criteria.

    + Collaborate with healthcare providers and the authorization team to ensure timely review of services and requests, ensuring members receive authorized care.

    + Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of member care.

    + Escalate prior authorization requests to Medical Directors as needed to determine the appropriateness of care.

    + Assist with service authorization requests for a member’s transfer or discharge plans to ensure timely discharge between levels of care and facilities.

    + Collect, document, and maintain all members’ clinical information in health management systems to ensure compliance with regulatory guidelines.

    + Provide education to providers and interdepartmental teams on utilization processes to promote high-quality and cost-effective medical care.

    + Offer feedback on opportunities to improve the authorization review process for members.

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

    Essential Skills

    + Clinical review experience.

    + Case management expertise.

    + Health informatics proficiency.

     

    Additional Skills & Qualifications

     

    + Graduate from an Accredited School of Nursing or a Bachelor's degree in Nursing with 2 – 4 years of related experience.

    + Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.

    + Knowledge of Medicare and Medicaid regulations preferred.

    + Familiarity with utilization management processes preferred.

    + Licensed Practical Nurse (LPN) - State Licensure required.

    + For Health Net of California: RN license required.

    + For Superior Health Plan: RN license required.

     

    Work Environment

     

    This is a remote position based in Iowa, offered on a contract basis.

     

    Job Type & Location

     

    This is a Contract to Hire position based out of West Des Moines, IA.

    Pay and Benefits

    The pay range for this position is $32.00 - $40.00/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 Nov 24, 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.