The Clinical Review Nurse - 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. 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. 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
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
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
Requirements
Active California LVN or RN license
3-5+ years of current clinical UM review
Experience with prior authorization in managed care or delegated environment
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-pace environment
Salary range
$62,400 - $93,600 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.
Benefits
Health insurance
Additional Information
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 .
Akidolabs · CA