Remote Clinical Review Nurse

Job Title: Remote Prior Authorization Registered NurseJob Description

We are seeking experienced Registered Nurses (RNs) to join a remote Prior Authorization team supporting Dual Eligible (Medicare and Medicaid) populations. In this role, you will review outpatient authorization requests, assess medical necessity, apply clinical guidelines, and ensure members receive timely and appropriate access to care. You will work collaboratively with providers, medical directors, and interdisciplinary teams while helping maintain high-quality, cost-effective healthcare services.

Responsibilities

• Perform medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria.
• Collaborate with healthcare providers and the authorization team to ensure timely review of services and/or requests, ensuring members receive authorized care.
• Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of care for members.
• Escalate prior authorization requests to Medical Directors as appropriate to determine the appropriateness of care.
• Assist with service authorization requests for members' transfer or discharge plans to ensure a timely discharge between levels of care 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/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
• Offer feedback on opportunities to improve the authorization review process for members.
• Comply with all policies and standards.

Essential Skills

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience in clinical review, utilization management, prior authorization, or case management.
• LPN - Licensed Practical Nurse - State Licensure required.
• RN license required for Health Net of California and Superior Health Plan.
• Experience in analyzing authorization requests and determining the medical necessity of services.

Additional Skills & Qualifications

• Clinical knowledge and ability to analyze authorization requests preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• RN Compact License.

Work Environment

This is a remote position, ideal for those who thrive in a fast-paced environment. The role involves working collaboratively with a team of healthcare professionals to ensure high-quality, cost-effective healthcare services. The work requires the use of health management systems and adherence to regulatory guidelines.

Job Type & Location

This is a Contract to Hire position based out of Sunrise, FL.

Pay and Benefits

The pay range for this position is $38.00 - $44.00/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 Oct 8, 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 actalentaccommodation@actalentservices.com 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.