Registered Nurse (RN) - Clinic
Actalent
Dallas, TX

Clinical Review Nurse - Prior Authorization

Job Title: Prior Authorization Nurse Job Description The Prior Authorization Nurse is responsible for analyzing all prior authorization requests to determine the medical necessity of services and appropriate levels of care in accordance with national standards, contractual requirements, and member benefit coverage. The role involves providing recommendations to the appropriate medical team to promote quality and cost-effectiveness of medical care. Responsibilities * Analyze prior authorization requests to determine medical necessity of services and appropriate levels of care. * Provide recommendations to the medical team to promote quality and cost-effective medical care. * Perform medical necessity and clinical reviews of authorization requests in accordance with regulatory guidelines and criteria. * Coordinate with healthcare providers and the authorization team to ensure timely review of services and/or requests. * Assess the medical necessity of care in coordination with healthcare providers and interdepartmental teams. * Escalate prior authorization requests to Medical Directors as appropriate. * Assist with service authorization requests for member transfer or discharge plans to ensure timely discharge between levels of care and facilities. * Collect, document, and maintain all member clinical information in health management systems to ensure compliance with regulatory guidelines. * Provide education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care. * Offer feedback on opportunities to improve the authorization review process. * Perform other duties as assigned. * Comply with all policies and standards. Essential Skills * Graduate from an Accredited School of Nursing or a Bachelor's degree in Nursing. * 2-4 years of related experience. * LPN - Licensed Practical Nurse - State Licensure required. * Clinical knowledge and ability to analyze authorization requests and determine medical necessity of services. Additional Skills & Qualifications * Knowledge of Medicare and Medicaid regulations. * Knowledge of utilization management processes. Work Environment The position operates from 8 AM to 5 PM CST, Monday to Friday, with rotating weekends and no overtime. The role is remote, except for candidates based in California and New York. On the first day, the new hire will set up all systems and meet with their preceptor. The initial training includes a four-week learning journey followed by training with a preceptor on the team. 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. Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through: * Hiring diverse talent * Maintaining an inclusive environment through persistent self-reflection * Building a culture of care, engagement, and recognition with clear outcomes * Ensuring growth opportunities for our people 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 process due to a disability, please email [email protected] for other accommodation options.