Senior Clinical Review Nurse - Complex Cases & Prior Authorization

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

Benefits offered by this job

Equal opportunity employer

Job summary

Akido Labs, Inc. is seeking a Clinical Review Nurse for Complex Case Management and Prior-Authorization in California.

You will review and process prior authorizations, evaluate medical necessity, and coordinate with providers to ensure timely, accurate determinations within the Utilization Management team. You will lead care management for high-risk populations, document decisions, and ensure compliance with health plan requirements.

Qualifications

• 3-5+ years of current clinical UM review.
• Experience with prior authorization in managed care.
• 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, diagnostics, and DME.
• Evaluate requests using guidelines and plan criteria.
• Review medical records for completeness and medical necessity.
• Identify missing documentation and coordinate with providers.
• Lead interdisciplinary care management for high-risk patients.
• Document determinations accurately in the system.
• Maintain compliance with DMHC and CMS requirements.
• Communicate with physicians and facilities for information and status updates.
• Prepare clinical summaries for Medical Director decisions.
• Route denials to Medical Director when needed.
• Collaborate with UM Coordinators, Claims, Eligibility, and Operations.
• Contribute to care plans with Medical Director and patients.

Skills

UM review

Complex case management

Prior authorization

California regulations

EZCap familiarity

Communication

Tools

EZCap

Job description

Akido Labs, Inc. is seeking a Clinical Review Nurse for Complex Case Management and Prior-Authorization in California.

You will review and process prior authorizations, evaluate medical necessity, and coordinate with providers to ensure timely, accurate determinations within the Utilization Management team. You will lead care management for high-risk populations, document decisions, and ensure compliance with health plan requirements.