Clinical Review Nurse; Remote

Job Title:

Clinical Prior Authorization Reviewer

This role focuses on reviewing prior authorization requests to determine the medical necessity of services and the appropriate level of care. The position ensures that each request aligns with national standards, contractual requirements, and member benefit coverage, while supporting quality and cost-effective medical care. The reviewer also evaluates more complex cases and collaborates with the medical team to support sound clinical decisions.

• Review prior authorization requests on a routine basis to assess medical necessity of services.
• Determine the appropriate level of care for requested services in accordance with national clinical standards and guidelines.
• Verify that requested services comply with contractual requirements and the members benefit coverage.
• Conduct clinical reviews of more complex authorization requests and identify any issues or risks.
• Provide clear, well-supported recommendations to the appropriate medical team for complex cases.
• Promote quality and cost-effective medical care through thorough utilization review and decision-making.
• Apply utilization management policies and regulations consistently when evaluating authorization requests.
• Document clinical review findings and recommendations accurately and in a timely manner, using required systems such as One Note.
• Collaborate with clinical and non-clinical team members to support efficient prior authorization processes.
• Maintain up-to-date knowledge of relevant clinical criteria (such as Inter Qual and Milliman) and organizational policies.

• Demonstrated experience performing clinical review of prior authorization requests.
• Prior experience in prior authorization (PA) processes.
• Experience using Inter Qual and/or Milliman clinical criteria for medical necessity determinations.
• 24 years of related clinical review or utilization management experience is preferred.
• Familiarity with national standards for medical necessity and level-of-care determinations.
• Comfort working with clinical guidelines and evidence-based criteria such as Inter Qual and Milliman.

This position operates in a structured, clinical review environment with a focus on accuracy, compliance, and collaboration. The role follows a Sunday through Thursday schedule, with shifts determined by team needs and coverage requirements. Possible shifts are aligned to Pacific and Central time zones and may include 7:00 a.m. to 4:00 p.m., 8:00 a.m. to 5:00 p.m., or 9:00 a.m. to 6:00 p.m. Work is performed using standard office and clinical review tools, including electronic documentation systems such as One Note, and requires consistent adherence to utilization management policies and procedures.

This is a Contract position based out of Portland, OR.

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

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

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)

This is a fully remote position.

This position is anticipated to close on Oct 15, 2026.

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