Clinical Review Nurse - Prior Authorization - J00927

Clinical Review Nurse - Prior Authorization - J00927

BC Forward is looking for Clinical UR Nurse (Prior Authorization) - Remote

Position: Clinical UR Nurse (Prior Authorization) - Remote

Location: Remote - Indiana

Anticipated Start date : 09/01
Duration: 3 months Contract to Hire
Shift Schedule: Monday-Friday, 8:00 AM - 5:00 PM EST | Occasional overtime (rare) | On-call rotation required
Pay Rate: $42.82/hr on W2
Need: Graduate of an accredited nursing program (Diploma, ADN, or BSN) with 2-4 years of clinical experience in acute care, case management, or utilization review; current, unrestricted LPN or RN license in Indiana or a compact state.


Job Description:
Position Purpose
The Clinical Utilization Review Nurse performs comprehensive clinical evaluations of prior authorization requests to determine medical necessity, appropriate level of care, and alignment with national standards, contractual obligations, and member benefit coverage. This role supports high-quality, cost-effective healthcare by providing evidence-based recommendations to internal medical teams and collaborating with providers to ensure timely access to care. The position operates remotely and plays a critical role in compliance with regulatory requirements, including those set forth by CMS.

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Key Responsibilities

• Conduct thorough medical necessity and clinical reviews of prior authorization requests for outpatient, ambulatory services, procedures, and durable medical equipment (DME), using evidence-based criteria such as InterQual (preferred).
• Evaluate requests in accordance with federal and state regulations, payer contracts, clinical guidelines, and member-specific benefits.
• Collaborate directly with healthcare providers via phone (outbound and inbound) to gather clinical information, clarify documentation, and support timely decision-making.
• Coordinate with interdisciplinary teams, including authorization specialists and medical directors, to assess appropriateness of care and facilitate seamless care transitions.
• Escalate complex or non-routine cases to Medical Directors when clinical judgment or exceptions are required.
• Support discharge planning and patient transfers between levels of care or facilities by reviewing service requests and ensuring continuity.
• Accurately collect, document, and maintain member clinical data in health management systems, ensuring compliance with HIPAA, NCQA, CMS, and other regulatory standards.
• Assist in educating providers and internal teams on utilization management processes, policy updates, and best practices to improve quality and efficiency.
• Identify and provide feedback on opportunities to optimize the prior authorization process, reduce delays, and enhance member and provider experience.
• Participate in on-call rotations with team members to support after-hours coverage as needed.
• Perform other duties as assigned.
• Maintain strict adherence to company policies, procedures, and ethical standards.

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Education & Experience

• Required:
  • Graduation from an accredited School of Nursing (Diploma, Associate, or Bachelor's degree)
  • OR Bachelor of Science in Nursing (BSN)
  • 2-4 years of progressive clinical experience in acute care, case management, utilization review, or managed care settings
• Preferred Qualifications:
  • Experience in utilization management (UM) or prior authorization processes
  • Familiarity with InterQual or MCG guidelines
  • Knowledge of Medicare, Medicaid, and CMS regulatory requirements
  • Background in outpatient, ambulatory surgery, or DME review

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Licensure & Certification

• Required:
  • Current, unrestricted LPN or RN license in the state of Indiana (or compact state)
  • For roles supporting Health Net of California or Superior HealthPlan: RN license is required

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Technical & Professional Requirements
? Must-Have Competencies (Non-Negotiable)

Computer Proficiency & Technical Literacy

• Must be highly proficient with electronic health records (EHR), case management systems, and Microsoft Office Suite
• Ability to troubleshoot basic technical issues independently (e.g., connectivity, system access, software navigation)

Clinical Critical Thinking & Decision-Making

• Demonstrated ability to interpret clinical documentation, apply medical necessity criteria, and make sound, defensible judgments under time constraints

Communication & Interpersonal Skills

• Excellent verbal communication skills; must be comfortable engaging providers over the phone in a professional, collaborative manner

?? Nice-to-Have (Preferred)

• Prior experience in utilization management or prior authorization in a health plan or managed care environment
• Working knowledge of InterQual or similar clinical decision support tools
• Exposure to CMS regulations, especially related to prior authorization turnaround times and transparency rules

?? Disqualifiers

• Lack of basic computer literacy or inability to work independently in a remote tech environment
• Unexplained gaps in employment history (candidate must be prepared to provide reasonable explanation)
• Inability to maintain a professional, distraction-free work environment at home (e.g., lack of reliable childcare if needed, frequent background noise during calls)

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Performance Indicators & Success Metrics

Metric
Expectation

Case Volume
Average of18 cases per day

Timeliness
Meet or exceedregulatory and contractual turnaround times(e.g., standard/expedited decisions)

Accuracy
High accuracy in clinical assessments and documentation; low error rate in system entries

Provider Engagement
Positive feedback from providers on clarity, timeliness, and professionalism

Compliance
100% adherence to privacy, regulatory, and audit requirements

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Best-in-Class vs. Average Candidate
?

Attribute
Top-Tier Candidate
Average Candidate

Computer Efficiency
Self-sufficient troubleshooter; fast navigation of multiple systems; minimal IT support needed
Basic user; may require assistance with technical issues

Prior Auth / UM Experience
Proven track record in managed care UM; understands payer workflows and regulatory timelines
Limited or indirect exposure to prior authorization

Critical Thinking & Communication
Strong clinical judgment; articulate, confident phone interactions with providers; proactive problem-solving
Follows protocols but struggles with ambiguity or complex cases

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Work Environment

• Fully remote position - must have:
  • Secure, high-speed internet connection
  • Quiet, private workspace
  • Computer provided by employer (if applicable), but environment must support professional telephony and video conferencing
• On-call rotation shared among team members (infrequent)
• Expected to be available during core business hours (8 AM - 5 PM EST)

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Why Join Us?
This temporary role offers the opportunity to contribute meaningfully to regulatory compliance and patient care during a pivotal time in healthcare policy. You'll work alongside experienced clinical and operational teams, gain exposure to national utilization standards, and help shape a more transparent, equitable prior authorization process-all from the flexibility of a remote role.

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Equal Opportunity Employer
MHS Indiana provides equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, or genetics.


About BCforward

Founded in 1998, BCforward is a Black-owned global leader in workforce management and digital product delivery solutions, headquartered in Indianapolis, IN. With a worldwide team of over 6,000 consultants, BCforward is dedicated to empowering human potential through its core values: People-Centricity, Excellence, and Diversity.

As an industry pioneer, BCforward provides a best-in-class workplace, fostering a culture of accountability, innovation, and optimism. Committed to equal opportunity employment, the company champions diversity and inclusion, striving to create a positive impact for its clients, employees, and communities.

Interested candidates please send resume in Word format Please reference job code 241482 when responding to this ad.

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