Clinical Review Nurse - Complex Case Management and Prior-Authorization
Core
Review prior authorization requests and manage complex cases for high-risk populations to ensure medical necessity and compliance with health plan guidelines.
Role type
Senior Utilization Management Nurse (Complex Case Management & Prior Authorization)
Builds
Prior authorization determinations and evidence-based care plans for members in a California managed care environment
Domain
Healthcare / Utilization Management / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical assessment, medical necessity review, prior authorization workflows, care plan development, regulatory compliance, interdisciplinary collaboration
Preferred skills
EZCap system proficiency, delegated MSO/health plan environment experience, Certified Case Manager (CCM) certification, California managed care regulations knowledge
Technologies
EZCap
Responsibilities
Review and process prior authorizations for outpatient services, procedures, and referrals; Evaluate requests using MCG guidelines and health plan criteria; Lead interdisciplinary care management for high-risk populations; Coordinate with providers to obtain missing clinical information; Document authorization activities and decision rationale in the system; Route denial cases to Medical Directors; Conduct monthly care management outreach and medication reviews.
Seniority
Mid-Senior, hands-on IC
