Clinical Review Nurse - Prior Authorization

About Akido

Akido is a pioneering AI-driven healthcare provider addressing the national physician shortage by combining advanced technology with an extensive medical network. Operating in California, Rhode Island, and New York, Akido serves over 500,000 patients offering primary and specialty care across 26 disciplines, including support for underserved populations such as those unhoused and ride-share drivers. Established in 2015, Akido continues to advance its care models and innovate with the ScopeAI clinical platform.

Position Overview

The Clinical Review Nurse dedicated to Prior Authorization operates within the Utilization Management (UM) team, focusing exclusively on prior authorization processes. This role ensures that authorization requests meet medical necessity, comply with health plan requirements, and follow regulatory standards within California's managed care setting. Collaboration with providers, Medical Directors, and operational units is essential to facilitate accurate and timely authorization decisions.

Key Duties

• Assess and process prior authorization requests related to outpatient treatments, procedures, diagnostic tests, specialty referrals, durable medical equipment, and ancillary services.
• Apply MCG clinical guidelines and health plan policies to evaluate requests.
• Examine medical records and clinical documents to verify completeness, accuracy, and necessity per clinical and health plan standards.
• Identify and request additional information from providers when documentation is incomplete or unclear.
• Ensure all clinical evaluations and determinations are thoroughly and accurately recorded in internal systems.
• Maintain adherence to DMHC prior authorization mandates, CMS requirements, health plan delegation protocols, and established turnaround and notification timelines.
• Communicate with medical professionals and facilities to obtain or provide updates on authorization statuses.
• Recognize cases needing further clinical review and prepare summaries for Medical Director decisions.
• Route cases recommended for denial to Medical Directors appropriately.
• Keep comprehensive notes and rationales within the EZCap system for all cases handled.
• Work collaboratively with UM Coordinators and other departments such as Claims, Eligibility, and Operations to support efficient processes.

Qualifications

• Valid Licensed Vocational Nurse (LVN) or Registered Nurse (RN) credential in California.
• Between 3 to 5+ years of recent experience in clinical Utilization Management review.
• Prior authorization expertise within managed care or delegated settings is essential.
• Familiarity with MCG criteria, medical necessity analysis, and prior authorization operations.
• Experience using EZCap system is preferred.
• Background working with delegated Managed Service Organizations (MSO) or health plan environments is advantageous.
• Understanding of California managed care legislation including DMHC and CMS standards.
• Strong clinical evaluation skills, attention to detail, and effective communication abilities.
• Able to balance multiple priorities in a dynamic, fast-paced environment.

Compensation

The salary for this role ranges from $62,400 to $93,600 annually.

Equal Opportunity Employer

Akido Labs, Inc. embraces diversity and encourages candidates from all backgrounds and experiences to apply.