Clinical Review Nurse: Complex Case Mgmt & Prior-Auth

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 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