Clinical Review Nurse - Complex Case Management and Prior-Authorization

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