Akido
Clinical Review Nurse - Prior Authorization
Chino, California
Sponsorship not specified$62k-$94kDetected 46 days ago
Communication
About the role
- 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.
Responsibilities
- Document all authorization activities accurately within EZCap, maintaining detailed notes, status updates, and decision rationale
- Collaborate with UM Coordinators, Claims, Eligibility, and Operations
- Ability to manage competing priorities in a fast-pace environment
- This role focuses exclusively on prior authorization activities within the Utilization Management (UM) department and supports delegated UM operations in a California managed care environment.
Requirements
- 3-5+ years of current clinical UM review
- Experience with prior authorization in managed care or delegated environment
- Knowledge of California managed care regulations (DMHC/CMS)
Nice to have
- Experience with EZCap (preferred)
Compensation
- $62,400 - $93,600 USD
Benefits
- 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.
- 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
- Knowledge of MCG criteria, medical necessity review, and prior authorization workflows
- Experience in a delegated MSO or health plan environment (preferred)
Equal opportunity
- 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.
This listing is sourced directly from Akido's careers page and normalized into a canonical job model.