Clinical - Clinical Review Nurse - Prior Authorization - J00927

Job Description:

Job Title: Utilization Review Clinician / Clinical Review Nurse Prior Authorization
Location: Remote (Must be based in Arizona and hold independent licensure in AZ)
Duration: 5 months (Possibility of extension)
Schedule: Standard business hours (M-F, 8am 5pm). No overtime required.

About the Role
We are seeking a Behavioral Health Utilization Review Clinician to join our UM team supporting behavioral health authorization reviews. In this role, you will analyze prior authorization and continued stay requests for behavioral health and substance abuse services, ensuring medical necessity, compliance with CMS guidelines, and timely turnaround (7-day TAT per CMS final rule).

Key Responsibilities

• Perform clinical reviews of authorization requests for behavioral health and substance abuse services (prior auth and continued stay).

• Determine medical necessity of services in accordance with regulatory guidelines, medical policies, and benefit coverage.

• Collaborate with healthcare providers, Medical Directors, and BH Case Managers to ensure appropriate level of care and continuity of care.

• Support discharge planning, treatment reviews, and medical record audits to ensure compliance and quality of care.

• Educate providers and interdepartmental teams on behavioral health utilization management processes.

• Collect and document member clinical information in health management systems for compliance with CMS and state regulations.

• Provide feedback and recommendations to improve the prior authorization process and overall member outcomes.

Qualifications

• Education: Graduate of an accredited school of nursing OR Bachelor's degree in Nursing OR Master's in Social Work, Counseling, or related field.

• Licensure (Required must be active and independent in AZ):

  • RN (AZ state or compact license) OR

  • LCSW, LMHC, LPC, LMFT, LMHP (Arizona independent licensure).

• Experience:

  • Minimum 2+ years in behavioral health field (clinical experience required).

  • Experience in utilization review, medical necessity determination, or prior authorization strongly preferred.

  • Knowledge of Medicare/Medicaid regulations and behavioral health UM processes is a plus.

• Skills:

  • Strong clinical judgment in behavioral health care.

  • Excellent computer proficiency and ability to work across multiple systems.

  • Strong organization and multitasking skills.