Clinical Review Nurse - Outpatient Prior Authorization

Job Title: Registered Nurse - Duals Program Utilization Management Job Description Join a dynamic team in a brand new 2026 program dedicated to managing the Duals line of business, combining Medicare and Medicaid benefits into a single comprehensive service. This program operates in eight states and may expand further in 2027. The role involves managing the complexities of both Medicare and Medicaid requirements simultaneously, focusing on outpatient concurrent reviews. The outpatient prior authorization team reviews authorization requests for Medicare, Medicaid, and Dual Eligible populations to ensure services meet medical necessity criteria and regulatory requirements while supporting timely access to care. Responsibilities Review outpatient prior authorization requests for Dual Eligible populations (Medicare and Medicaid), Work assigned cases from designated work queues and daily assignments, Utilize TrueCare Classic and Cloud platforms to complete utilization management reviews, Apply clinical criteria and organizational guidelines to determine medical necessity and appropriateness of requested services, Document review findings and authorization decisions accurately and timely, Communicate with providers and internal departments as needed regarding authorization requests and clinical information. Productivity target of approximately 1.85 reviews per hour , Meet established turnaround time requirements, Maintain quality and documentation standards, Adhere to departmental workflows and regulatory requirements. Opportunity to work across Dual eligible populations, collaborative and supportive team environment, fully remote position with established workflows, resources and leadership support, direct impact on member access to care and authorization determination. Essential Skills Registered Nurse (RN) with a compact license. Experience in Utilization Management (UM). Proficient in prior authorization. Experience applying InterQual, MCG, or similar clinical criteria Ability to review outpatient prior authorizations requests for medical necessity Strong computer skills and ability to use medical management software. Additional Skills & Qualifications Experience with outpatient prior authorization. Experience in acute care, Medicaid, and Medicare. Work Environment The team is a fully remote group of prior authorization nurses who work collaboratively in a supportive and highly engaged environment. Team members work closely together and have access to leadership and peer support as needed .The team is focused on quality, regulatory compliance, productivity, and timely member access to care. Schedule : Tuesday-Saturday OR Sunday-Thursday Central, Pacific, or Mountain time 8-5pm Job Type & Location This is a Contract to Hire position based out of St. Louis, MO. Pay and Benefits The pay range for this position is $34.00 - $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) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on Sep 10, 2026. 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 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service. 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. San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records. Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.