Clinical Review Nurse - Complex Case Management and Prior-Authorization

📋 Description

• Review and process prior authorizations for outpatient services, procedures, diagnostic testing
• Evaluate requests using MCG guidelines and health plan criteria and policies
• Review medical records and supporting clinical documentation to ensure completeness, accuracy, and
• Identify missing or insufficient documentation and coordinate with providers for additional
• Support case management for members with complex or high-risk care needs, including care
• Ensure all clinical determinations are properly documented in the system

🎯 Requirements

• 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)