Clinical Review Nurse: Complex Care & Prior Authorization

Akido Labs, Inc.; Chino (CA); On-site; USD 78,000 - 103,000; Full time

Job summary

Akido Labs, Inc. is seeking a Clinical Review Nurse to perform complex case management and prior authorization review in a California managed care setting. You will evaluate requests against MCG guidelines, review medical records, and coordinate with providers to ensure medical necessity and timely authorizations.

The role requires 3–5+ years in clinical UM review and familiarity with EZCap. You will lead interdisciplinary care management for high-risk patients, maintain documentation, and

Qualifications

• 3–5+ years of current clinical UM review.
• Experience with prior authorization in managed care or delegated environment.
• Experience with complex case management.
• Knowledge of MCG criteria, medical necessity review, and prior authorization workflows.
• Experience with EZCap (preferred).
• Experience in a delegated MSO or health plan environment (preferred).
• Knowledge of California managed care regulations (DMHC/CMS).
• Strong clinical assessment skills and attention to detail.
• Effective written and verbal communication.
• Ability to manage competing priorities in a fast-paced environment.

Responsibilities

• Review and process prior authorizations for outpatient services, procedures, diagnostic testing, specialty referrals, and DME and ancillary services
• Evaluate requests using MCG guidelines and health plan criteria and policies
• Review medical records and supporting clinical documentation to ensure completeness, accuracy, and medical necessity in accordance with established clinical guidelines and health plan requirements
• Identify missing or insufficient documentation and coordinate with providers for additional information
• Lead interdisciplinary care management for high-risk, medically and psychosocially complex populations, ensuring delivery of patient-centered, evidence-based care plans to reduce key utilization metrics
• Ensure all clinical determinations are properly documented in the system
• Maintain compliance with DMHC prior authorization requirements, CMS guidelines, health plan delegation standards, turnaround times, notification requirements, and documentation standards
• Communicate with physicians, medical groups, facilities, and ancillary providers to obtain additional clinical information and provide authorization status updates as needed
• Identify cases requiring clinical review and prepare clinical summaries for Medical Director determination
• Ensure cases requiring denial are routed appropriately to the Medical Director
• Document all authorization activities accurately within EZCap, maintaining detailed notes, status updates, and decision rationale
• Collaborate with UM Coordinators, Claims, Eligibility, and Operations
• Conduct comprehensive assessments and contribute to development of patient-centered care plans in collaboration with Medical Director
• Perform monthly care management outreach, medication review, and specialist/community resource coordination, documenting time and activities

Skills

Utilization management review

Prior authorization workflows

Complex case management

Regulatory knowledge (DMHC/CMS)

MCG criteria familiarity

Communication skills

Tools

EZCap

Job description

Akido Labs, Inc. is seeking a Clinical Review Nurse to perform complex case management and prior authorization review in a California managed care setting. You will evaluate requests against MCG guidelines, review medical records, and coordinate with providers to ensure medical necessity and timely authorizations.

The role requires 3–5+ years in clinical UM review and familiarity with EZCap. You will lead interdisciplinary care management for high-risk patients, maintain documentation, and