Medical Review Nurse (RN)

Job Title: Medical Review Nurse (RN)
Location: 100% Remote (Florida-based only)
Duration: 3+ Months (Possible Extension)

Schedule: Monday – Friday, 8-hour days
Shift: Standard Day Shift
Remote Work: Yes – Fully Remote
Rotation: Weekend/holiday hours required on a rotating basis
 
Position Summary:
The Medical Review Nurse is responsible for reviewing, authorizing, and coordinating service requests for Client members under Medicare Prior Authorization (Pre-Service). This position ensures clinical decisions are compliant with CMS rules, coverage guidelines, and established clinical criteria such as InterQual. The nurse communicates with providers and occasionally members and refers cases to Medical Directors when necessary.
 
Essential Functions:

• Review and authorize clinical referral/authorization requests according to compliance standards and timelines
• Evaluate benefit coverage and medical necessity for complex or unclear cases
• Collaborate with Medical Directors for potential denials
• Conduct clinical research and document findings when criteria are not clearly met
• Support non-clinical staff in processing Prior Authorization requests
• Maintain thorough and accurate documentation of all prior authorization activities
• Collaborate across departments, including Claims, Utilization Management, Quality, and Appeals
• Handle incoming provider calls regarding authorizations; log calls and responses in electronic systems
• Provide accurate, timely information to provider offices
• Maintain call center productivity metrics and professional customer service standards
• Use multiple systems simultaneously to resolve medical review or authorization tasks

 
Required Qualifications:

• Licensure: Active RN license in the state of Florida
• Experience:
  • 0–2 years of relevant experience in clinical review or prior authorization
  • Prior call center experience preferred
  • Experience using nationally recognized clinical criteria (InterQual)
  • Familiarity with Medicare regulations and CMS guidelines
• Skills & Abilities:
  • Strong understanding of medical terminology
  • Proficient with Microsoft Office Suite
  • Ability to multitask and navigate multiple computer systems/screens efficiently
  • Excellent verbal and written communication skills
  • Professional and courteous phone demeanor