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Clinical - Clinical Review Nurse - Prior Authorization - J00927
Clinical - Clinical Review Nurse - Prior Authorization - J00927Pacer Group • OR, United States
Clinical - Clinical Review Nurse - Prior Authorization - J00927

Clinical - Clinical Review Nurse - Prior Authorization - J00927

Pacer Group • OR, United States
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Job description :

Job Title : Clinical Review Nurse Prior Authorization

Location : Remote Oregon

Duration : 3 months (Contract-to-Hire, Possible Extension)

Schedule : Monday Friday, 8 : 00 AM 5 : 00 PM PST (Occasional weekend / holiday coverage as needed)

Position Overview :

  • We are seeking a dedicated Clinical Review Nurse to perform prior authorization (PA) and inpatient (IP) reviews, ensuring that healthcare services meet medical necessities, regulatory guidelines, and member benefit coverage.
  • This role requires strong clinical judgment, attention to detail, and effective communication with providers and internal teams.

Key Responsibilities :

  • Perform medical necessities and clinical reviews of PA and IP authorization requests according to regulatory guidelines and internal criteria.
  • Coordinate with healthcare providers and interdepartmental teams to ensure timely approval of services.
  • Escalate complex requests to Medical Directors when necessary.
  • Support member transfers or discharge planning to ensure seamless transitions across care levels and facilities.
  • Collect, document, and maintain all clinical information in health management systems, ensuring compliance with regulations.
  • Provide education to providers and team members on utilization management processes.
  • Identify opportunities to improve PA / IP review workflows and enhance efficiency.
  • Adherent to all company policies, compliance standards, and performance metrics.

    • Required Qualifications :

  • LPN or RN with active state licensure in Oregon.
  • Minimum 2 years of experience in prior authorization or inpatient authorization review, preferably with insurance companies.
  • Clinical knowledge to assess medical necessity and review authorization requests.
  • Familiarity with Medicare and Medicaid regulations preferred.
  • Strong organizational, problem-solving, and multitasking skills.
  • Ability to work independently while contributing to a collaborative team environment.
  • Flexibility to work occasional weekends or holidays.

    • Preferred Qualifications :

  • RN licensure preferred.
  • Prior experience in utilization management processes.
  • Knowledge of healthcare provider operations and insurance claim processes.

    • Key Performance Indicators :

  • Complete up to 20 authorization reviews per day.
  • Maintain compliance with regulatory and organizational standards.
  • Positive collaboration with team members and providers.
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    Prior Authorization • OR, United States