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Clinical Review Nurse - Prior Authorization

Spectraforce Technologies

United States, North Carolina, Raleigh

500 West Peace Street (Show on map)

Apr 04, 2025

Job Title: Clinical Review Nurse - Prior Authorization

Job Location: Remote - North Carolina

Job Duration: 3 Months (Temp to perm)

Shift: 8 am - 5 pm

Responsibilities:

As a member of this team you will review medical records, collaborate with other disciplines within our plan, and rely primarily on state Medicaid policy to clinically review outpatient medical prior authorization requests from providers to better serve our members and their individual health needs.
We have a very tight knit team that has worked together for many years and is always welcoming and helpful in precepting and guiding any new hire we bring on.
We communicate daily, answering questions for each other and providing support where needed in our team groupchat.
We also have 3 senior nurses and 1 team lead ready and available to assist with day to day questions and process concerns as you learn your new role and systems.
Each nurse receives an assignment each morning, and the expectation for daily productivity is to complete >=16 authorizations, which is about 2 per hour.
Within this role you will gain experience reviewing NC state Medicaid policy, use of InterQual and TruCare systems, interdisciplinary work with discharge planners, case managers, and experienced medical directors.
You will review a variation of service types ranging from DME and Therapy to Outpatient Surgery and Home Health services, and many more.
This will aid in expanding your medical knowledge and improve overall understanding of the insurance side of healthcare that is often misunderstood.
Our team is knowledgeable, compassionate, driven and made up of some incredible nurses that have been doing this work for many years and provide priceless experience for anyone willing to learn and grow.

Must haves:

Prior Authorization experience

Nice to haves:

TruCare MCG and/or InterQual experience, diverse nursing experience

Disqualifiers:

No prior authorization experience (marie peppers class is not experience)

Qualifications:

Education/Certification	Required: Certificate/Associates	Preferred: Bachelor's Degree
Licensure	Required: LPN	Preferred: BSN