Clinical Review Nurse

Job Description

Job Description

Job Title: Medical Authorization Review Specialist

Job Description

We are seeking a dedicated Medical Authorization Review Specialist to analyze all prior authorization requests and determine the medical necessity of services. The role ensures that care is provided in accordance with national standards, contractual requirements, and a member's benefit coverage. Your insights will contribute to promoting quality and cost-effective medical care.

Responsibilities

• Perform medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in line with regulatory guidelines and criteria.
• Collaborate with healthcare providers and the authorization team to ensure timely review of services, ensuring members receive authorized care.
• Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of member care.
• Escalate prior authorization requests to Medical Directors when needed to determine the appropriateness of care.
• Assist with service authorization requests for member transfers or discharge plans, ensuring timely discharge between care levels and facilities.
• Collect, document, and maintain all members' clinical information in health management systems to ensure compliance with regulatory guidelines.
• Provide education to providers and interdepartmental teams on utilization processes to promote high-quality, cost-effective medical care.
• Offer feedback on opportunities to enhance the authorization review process for members.
• Comply with all policies and standards and perform other duties as assigned.

Essential Skills

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience in clinical review or prior authorization.
• LPN - Licensed Practical Nurse - State Licensure required.
• RN license required for Health Net of California and Superior Health Plan.

Additional Skills & Qualifications

• Clinical knowledge and ability to analyze authorization requests.
• Knowledge of Medicare and Medicaid regulations preferred.
• Familiarity with utilization management processes.
• Previous experience with prior authorization is a plus.
• Willingness to learn and a positive attitude.

Work Environment

The role involves working with diverse interdepartmental teams and healthcare providers. The position requires handling up to 20 authorization reviews per day while ensuring high compliance with regulatory guidelines. The candidate should be prepared to work in a fast-paced environment, focusing on delivering quality and cost-effective medical care.

Pay and Benefits

The pay range for this position is $35.00 - $40.00/hr.

Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully onsite position in Charlotte,NC.

Application Deadline

This position is anticipated to close on Nov 6, 2025.

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.

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 due to a disability, please email [email protected] for other accommodation options.