New

Clinical Review Nurse - Prior Authorization

United States, Texas, Houston

May 21, 2025

Title: Clinical Review Nurse - Prior Authorization

Location: Remote

Duration: 06 Months (Contract to Hire)

Job Description:

Reviewing authorization requests
Utilizing evidence-based criteria and making a medically necessary determination.
Outreach calls to providers to request additional details if applicable.

They will not be completing any calls to members.

Required Skills/Experience:		Preferred Skills/ Experience:
1.	ICU, Medical Surgical background, bedside experience (Home health nurses)	1.	Medicare experience ( Utilization Management with Medicare)
2.	Utilization Review (Prior Authorization)	2.	CCM Certification
3.	Acute Care	3.	ACLS Certification
Education Requirement:	Bachelor's with RN or RN without Bachelors is okay too	Education Preferred:
Software Skills Required:	TruCare is the system the team uses so if they have experience it is beneficial. Microsoft Office Systems
Required Certifications:	RN is what the team is really looking for (If the person has an RN license without a bachelors, they are okay) LPN - Licensed Practical Nurse - State Licensure required Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.	Required Testing:	n/a