Clinical Review Nurse - Prior Authorization

The Opportunity

• 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

Who you are

• 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

Pay

Salary range: $62,400 - $93,600 USD