Clinical Review Nurse - Prior Authorization (Remote IN)

BC Forward is looking for Clinical Review Nurse - Prior Authorization (Remote) in Indiana

About BCforward

Founded in 1++8, BCforward is a Black-owned global leader in workforce management and digital product delivery solutions, headquartered in Indianapolis, IN. With a worldwide team of over 6,000 consultants, BCforward is dedicated to empowering human potential through its core values: People-Centricity, Excellence, and Diversity.

As an industry pioneer, BCforward provides a best-in-class workplace, fostering a culture of accountability, innovation, and optimism. Committed to equal opportunity employment, the company champions diversity and inclusion, striving to create a positive impact for its clients, employees, and communities.



Position Title: Clinical Review Nurse - Prior Authorization (Remote)

Locations: Remote - Indiana (Only Locals)

Anticipated Start Date: 04/07

Expected Duration: 3 Months

Job Type: Contract with possible extension

Shift: Hours: Monday – Friday, 8 AM – 5 PM EST (Training and regular work schedule)

Pay Rate $45.00/hr. on W2

Need: Bachelors Degree in Nursing and 2-4yrs of relevant exp. RN licensure (RN preferred over LPN).



Job Description:

Position Purpose:

The Prior Authorization Nurse is responsible for reviewing prior authorization requests to assess medical necessity, determine the appropriate level of care, and ensure alignment with national standards, contractual requirements, and member benefit coverage. This role collaborates with healthcare providers and internal teams to promote high-quality, cost-effective medical care.

Review prior authorizations for medical necessity for outpatient/ambulatory services, procedures and DME items

About 18 cases a day – phone calls to providers

Education & Certification Requirements

Required: Graduate from an Accredited School of Nursing OR Bachelor’s degree in Nursing with 2 – 4 years of related experience.
Preferred: RN licensure (RN preferred over LPN).
Experience Requirements

Must-Have:
Computer proficiency – ability to troubleshoot issues independently.
Professional work environment – candidates must have appropriate workspace (childcare arrangements if applicable).
Nice-to-Have:
Utilization Management (UM) prior authorization experience.
InterQual knowledge (clinical decision support).
Best vs. Average Candidate Comparison

Top 3 Must-Have Hard Skills (Stack-Ranked by Importance):
Computer efficiency (troubleshooting technical issues independently).
Prior authorization knowledge (experience with UM, payer guidelines, and InterQual preferred).
Professionalism & communication skills (clear, polished communication with providers and internal teams).
Candidate Review & Selection Process

Prioritize candidates with strong technical skills and prior auth experience.
Assess level of experience in each must-have area.
Ensure candidates demonstrate a professional, reliable work setup.
Key Responsibilities:

Conduct medical necessity and clinical reviews of authorization requests to ensure compliance with regulatory guidelines and criteria.
Collaborate with healthcare providers and authorization teams to facilitate timely review and approval of services.
Coordinate with healthcare providers and interdepartmental teams to assess the medical necessity of care and ensure optimal patient outcomes.
Escalate complex prior authorization requests to Medical Directors for further review and determination of care appropriateness.
Assist in processing service authorization requests related to member transfers or discharge plans, ensuring smooth transitions between levels of care and facilities.
Accurately collect, document, and maintain member clinical information in health management systems to ensure compliance with regulatory requirements.
Provide education to healthcare providers and internal teams on utilization management processes to enhance the quality and efficiency of medical care.
Identify opportunities to improve authorization review processes and contribute to continuous quality improvement initiatives.
Perform other duties as assigned while adhering to company policies and industry standards.
Qualifications:

Education & Experience:

Graduate of an accredited School of Nursing or a Bachelor’s degree in Nursing.
2–4 years of relevant clinical experience.
Experience in analyzing authorization requests and determining medical necessity is preferred.
Knowledge of Medicare and Medicaid regulations is highly desirable.
Familiarity with utilization management processes is a plus.
Licensure & Certification:

LPN – Licensed Practical Nurse (State Licensure required).
This role requires strong clinical expertise, attention to detail, and the ability to work collaboratively to ensure timely and appropriate medical care for members.

Company Description
About BCforward: