Job Description
This role involves analyzing all prior authorization requests to determine the medical necessity of services and the appropriate level of care in accordance with national standards and contractual requirements. The successful candidate will provide recommendations to the medical team to promote quality and cost-effectiveness of medical care.
ResponsibilitiesPerform medical necessity and clinical reviews of authorization requests to determine 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 by reviewing requests concerning members and working with providers.Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of care for members.Escalate prior authorization requests to Medical Directors as necessary to determine the appropriateness of care.Assist with service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities.Collect, document, and maintain all member's 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.Perform other duties as assigned.Comply with all policies and standards.Essential SkillsClinical review and prior authorization experience.Licensed Practical Nurse (LPN) or Registered Nurse (RN) certification in Washington! 2-4 years of prior authorization experience.Experience with Electronic Health Portals.Strong time management skills.Attention to detail.Additional Skills & QualificationsGraduate from an Accredited School of Nursing or Bachelor’s degree in Nursing (BSN).True care experience is a plus.Clinical knowledge and ability to analyze authorization requests and determine the medical necessity of services.Knowledge of Medicare and Medicaid regulations.Knowledge of utilization management processes.Work Environment
This position is 100% remote with flexible scheduling. Candidates are required to work Monday through Sunday, with hours either 6am-2pm or 8am-5pm PST. A weekday day off cannot be Friday or Monday, and candidates are required to work at least one weekend day per week. A training schedule is set for Monday to Friday from 8AM-5PM PST for a three-week course, and cameras must be on during training. There is potential for the role to extend or convert to a full-time position.
Pay and BenefitsThe pay range for this position is $28.00 - $38.00/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 remote position.
Application Deadline
This position is anticipated to close on Aug 20, 2025.
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 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 actalentaccommodation@actalentservices.com for other accommodation options.