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Job Title: Prior Authorization NurseJob Description

The Prior Authorization Nurse plays a critical role in analyzing prior authorization requests to determine the medical necessity of services and the appropriate level of care. This position ensures compliance with national standards, contractual requirements, and a member's benefit coverage while providing recommendations to the medical team to promote 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.

+ Work 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 necessary to determine the appropriateness of care.

+ Assist with service authorization requests for member transfers 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 to members.

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

+ 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.

+ LPN - Licensed Practical Nurse - State Licensure required.

+ RN license required for Health Net of California and Superior Health Plan.

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

+ Knowledge of Medicare and Medicaid regulations.

+ Familiarity with utilization management processes.

Additional Skills & Qualifications

+ Experience with Medicaid line of business.

+ Experience reviewing outpatient service requests for medical necessity.

+ Familiarity with InterQual.

+ Experience working with medical directors and therapists.

Work Environment

The position involves working closely with healthcare providers, authorization teams, and interdepartmental teams. The role requires the use of health management systems to maintain compliance with regulatory guidelines. The work environment is collaborative, with a focus on ensuring timely and appropriate medical care for members.

Job Type & Location

This is a Contract position based out of Baton Rouge, LA.

Pay and Benefits

The pay range for this position is $34.00 - $38.00/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 Jan 21, 2026.

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.