Clinical Review Nurse - Complex Case Management and Prior-Authorization

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

Job summary

Akido is seeking a Clinical Review Nurse to drive prior authorization reviews and support complex case management within California's managed care framework. You will collaborate with providers, Medical Directors, and UM teams to ensure medical necessity and timely determinations using MCG guidelines and EZCap notes.

The role emphasizes compliance with DMHC/CMS regulations, accurate documentation, and effective communication with physicians and facilities, while advancing patient-centered care

Qualifications

• Active California RN license is required.
• 3–5+ years of current clinical UM review experience.
• Experience with prior authorization in managed care or delegated environments.
• Experience with complex case management.
• Knowledge of MCG criteria, medical necessity review, and prior authorization workflows.
• Experience with EZCap is 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, diagnostics, referrals, and DME.
• Evaluate requests using MCG guidelines and plan policies.
• Review medical records to ensure completeness and medical necessity.
• Identify missing documentation and coordinate with providers.
• Support case management for complex/high-risk members, with care coordination and follow-up.
• Document all determinations in the system with rationale.
• Ensure compliance with DMHC/CMS and health plan requirements.
• Communicate with physicians and facilities to obtain additional information.
• Prepare clinical summaries for Medical Director determinations.

Skills

Clinical UM review

Communication skills

Attention to detail

Prioritization

Documentation

Education

RN license (California)

CCM certification

Tools

EZCap

Job description

Akido builds AI-powered doctors. Akido is the first AI-native care provider, combining cutting-edge technology with a nationwide medical network to address America’s physician shortage and make exceptional healthcare universal. Its AI empowers doctors to deliver faster, more accurate, and more compassionate care.

Serving 500K+ patients across California, Rhode Island, and New York, Akido offers primary and specialty care in 26 specialties—from serving unhoused communities in Los Angeles to ride-share drivers in New York.

Founded in 2015 (YC W15), Akido is expanding its risk-bearing care models and scaling ScopeAI, its breakthrough clinical AI platform. Read more about Akido’s $60M Series B. More info at Akidolabs.com.

The Opportunity

The Clinical Review Nurse – Complex Case Management and Prior-Authorization is responsible for reviewing and processing prior authorization requests to ensure medical necessity, appropriate level of care, and compliance with health plan and regulatory requirements, as well as supporting complex case management for members with ongoing or high-risk care needs. This role is primarily focused on prior authorization review, with secondary responsibility for complex case management as the program grows within the Utilization Management (UM) department, and it supports delegated UM operations in a California managed care environment. The Clinical Review Nurse works closely with providers, Medical Directors, and operational teams to ensure timely and accurate authorization determinations in accordance with established clinical guidelines and delegation standards.

What you’ll do

• 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
• Support case management for members with complex or high-risk care needs, including care coordination and follow-up
• 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

Who you are

• Active California RN license (required)
• 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)
• Certified Case Manager (CCM) 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

Salary range: $78,000 USD - $103,000 USD

Akido Labs, Inc. is an equal opportunity employer, and we encourage qualified applicants of every background, ability, and life experience to contact us about appropriate employment opportunities.