What are the responsibilities and job description for the Clinical Review Nurse – Prior Authorization {166056} position at A-Line Staffing?
***3-4 Years of experience in Healthcare Prior Authorizations/Utilization Management/Managed Care REQUIRED***
***NV Nurse License REQUIRED***
Clinical Review Nurse – Prior Authorization (RN)
Remote (Must Reside in Nevada)
Contract to hire – 3 Months with Potential to Hire
Schedule: Monday–Friday | 8:00 AM – 5:00 PM PST
Training: 3 weeks | Monday–Friday | 8:00 AM – 5:00 PM PST (On-Camera Required, No Time Off During Training)
Job Overview
A-Line Staffing is seeking an experienced Clinical Review Nurse – Prior Authorization to support utilization management and prior authorization reviews in a fully remote role. This position focuses on reviewing clinical documentation to determine medical necessity and appropriate levels of care in accordance with national guidelines, regulatory requirements, and member benefit plans.
This is a non–member-facing role. The nurse may communicate with providers as needed but will not interact directly with members.
This is a contract opportunity with strong potential for permanent hire, and candidates with stable work histories are strongly preferred.
Key Responsibilities
- Review prior authorization requests to determine medical necessity and medical appropriateness of care
- Apply national clinical criteria, regulatory guidelines, and benefit coverage requirements during reviews
- Collaborate with healthcare providers and internal authorization teams to ensure timely service approvals
- Communicate with providers via phone, fax, or RFI requests to obtain additional clinical information when needed
- Escalate complex or high-risk cases to Medical Directors as appropriate
- Support authorization decisions related to transfers and discharge planning across levels of care
- Accurately collect, document, and maintain clinical information in utilization management systems
- Ensure all reviews comply with Medicare, Medicaid, HIPAA, and regulatory standards
- Provide feedback and recommendations to improve authorization workflows and review processes
- Assist with provider and internal team education related to utilization management processes
- Perform additional duties as assigned and comply with all policies and standards
Required Qualifications
- Active RN license in the state of Nevada (required)
- RN or BSN required (Graduate of an accredited school of nursing)
- 3–4 years of experience in Prior authorization/Utilization management
- Experience with Medicare/Medicaid required
- Medical terminology
- HIPAA guidelines
- Clinical documentation review
- Medical necessity determination
- Experience using utilization management systems such as TruCare
- Familiarity with InterQual or similar clinical criteria tools
Preferred Qualifications
- Knowledge of Medicare and Medicaid regulations
- Prior experience in health plan, managed care, or utilization review environments
- Strong clinical judgment and analytical decision-making skills
- Proficiency with Microsoft Office applications
If you are interested in this position and want to learn more, feel free to reach out to Chris with A-Line Staffing at chojsan@alinestaffing.com or apply to this posting!
INDSV
Job Types: Full-time, Contract
Pay: $40.00 - $42.00 per hour
Application Question(s):
- Describe your relevant experience in Healthcare Prior Authorizations/Utilization Management/Managed Care:
Experience:
- Healthcare Prior Auth/Utilization Management/Managed Care: 3 years (Required)
Work Location: Remote
Salary : $40 - $42