Clinical Review Nurse: Complex Care & Prior Authorization

Akido Labs; Chino (CA); On-site; USD 62,000 - 94,000; Full time

Job summary

Akido Labs is seeking a Clinical Review Nurse to lead complex case management and prior-authorization activities within our Utilization Management team in California. You’ll review outpatient requests, apply MCG criteria, coordinate with providers, and ensure timely, compliant determinations for our growing managed care programs.

The role requires an active California RN license, 3–5+ years of UM review, and experience with prior authorization workflows.

Qualifications

• 3-5+ years of current clinical UM review experience.
• Active California RN license is required.
• Experience with prior authorization in managed care or delegated environment.

Responsibilities

• Review and process prior authorizations for outpatient services, procedures, and diagnostics.
• Evaluate requests using MCG guidelines and health plan criteria.
• Review medical records for completeness and medical necessity.
• Coordinate with providers to obtain missing information.
• Support complex case management for high-risk members.
• Document all authorization activities in EZCap with rationale.
• Ensure compliance with DMHC/CMS delegation standards and timelines.
• Communicate authorization status with physicians and facilities.

Skills

UM review

Prior authorization

Complex case management

MCG criteria knowledge

EZCap experience

Tools

EZCap

Job description

Akido Labs is seeking a Clinical Review Nurse to lead complex case management and prior-authorization activities within our Utilization Management team in California. You’ll review outpatient requests, apply MCG criteria, coordinate with providers, and ensure timely, compliant determinations for our growing managed care programs.

The role requires an active California RN license, 3–5+ years of UM review, and experience with prior authorization workflows.