Clinical Review Nurse - Prior Authorization

About the role

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.

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
• 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
• 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-paced environment

Qualifications

• Strong clinical assessment skills and attention to detail
• Effective written and verbal communication
• Ability to manage competing priorities in a fast-paced environment

Skills

• Strong clinical assessment skills
• Attention to detail
• Effective written and verbal communication
• Ability to manage competing priorities in a fast-paced environment

Benefits

• Comprehensive benefits package
• Professional development opportunities
• Flexible work schedule

Pay

$62,400 - $93,600 USD

Schedule

Full-time