Knowledge of MCG criteria and medical necessity review
Familiarity with EZCap preferred
Certified Case Manager (CCM) preferred
Understanding of California managed care regulations (DMHC/CMS)
Strong clinical assessment skills
Effective communication skills
Ability to manage competing priorities in a fast-paced environment
Responsibilities
Review and process prior authorizations for various services
Evaluate requests using MCG guidelines and health plan policies
Review medical records for completeness and medical necessity
Identify and coordinate with providers for missing documentation
Lead care management for high-risk populations with evidence-based plans
Document clinical determinations accurately in the system
Maintain compliance with regulatory and health plan standards
Communicate with providers for clinical information and authorization updates
Prepare clinical summaries for Medical Director review
Route denial cases to the Medical Director appropriately
Document authorization activities in EZCap with detailed notes
Collaborate with UM Coordinators and other operational teams
Conduct assessments and contribute to patient-centered care plans
Perform outreach and medication reviews, documenting activities
Benefits
Comprehensive health insurance options
Retirement savings plan with employer match
Generous paid time off and holiday schedule
Professional development opportunities
Supportive work environment focused on team collaboration
Full Job Description
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. The key focus areas of this role are prior authorization review and 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
Lead interdisciplinary care management for high-risk, medically and psychosocially complex populations, ensuring delivery of patient-centered, evidence-based care plans to reduce key utilization metrics (eg., readmission rates)
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
