Akido
ClinicalReviewNursePriorAuthorization
“Clinical Review Nurse - Prior Authorization at Akido. Skills: Prior Authorization, Clinical Review, Managed Care. Review and process prior authorizations. Evaluate requests using MCG guidelines”
What You'll Achieve.
Ensure timely and accurate authorization determinations
What They're Looking For.
Must Have
Active California LVN or RN license, 3-5+ years of current clinical UM review, Experience with prior authorization in managed care or delegated environment, Knowledge of MCG criteria, medical necessity review, and prior authorization workflows, Knowledge of California managed care regulations (DMHC/CMS), clinical assessment skills, attention to detail, Effective written and verbal communication, Ability to manage competing priorities in a fast-pace environment
Nice to Have
Experience with EZCap, Experience in a delegated MSO or health plan environment
What You'll Do.
Review and process prior authorizations
Evaluate requests using MCG guidelines
Review medical records and supporting documentation
Identify missing or insufficient documentation
Ensure all clinical determinations are documented
Maintain compliance with DMHC requirements
Communicate with physicians and providers
Identify cases requiring clinical review
Prepare clinical summaries for Medical Director
Ensure cases requiring denial are routed
Document all authorization activities accurately
Maintain detailed notes
Collaborate with UM Coordinators
How You'll Work.
Team & Collaboration
Works closely with providers, Medical Directors, and operational teams; Coordinate with providers for additional information; Communicate with physicians, medical groups, facilities, and ancillary providers; Collaborate with UM Coordinators, Claims, Eligibility, and Operations
Communication Scope
Effective written and verbal communication
Applying for this Clinical Review Nurse - Prior Authorization role?
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