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Salary: USD 62,400 - 93,600 / annual
Akido Labs is an AI-native care provider serving 500K+ patients across California, Rhode Island, and New York, offering primary and specialty care in 26 specialties. Founded in 2015 (YC W15) and recently raised $60M in Series B funding, Akido combines cutting-edge AI technology with a nationwide medical network to address physician shortages and expand access to exceptional healthcare.
The Clinical Review Nurse – Complex Case Management and Prior Authorization role sits within the Utilization Management (UM) department and 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. The position also supports complex case management for members with ongoing or high-risk care needs, working closely with providers, Medical Directors, and operational teams in a California managed care environment.
Key responsibilities include:
- Review and process prior authorizations for outpatient services, procedures, diagnostic testing, specialty referrals, DME, and ancillary services
- Evaluate requests using MCG guidelines and health plan criteria and policies
- Review medical records and supporting clinical documentation for completeness, accuracy, and medical necessity
- Identify missing or insufficient documentation and coordinate with providers for additional information
- Support case management for members with complex or high-risk care needs, including care coordination and follow-up
- 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 clinical information and provide authorization status updates
- Identify cases requiring clinical review and prepare clinical summaries for Medical Director determination
- Route cases requiring denial 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 teams
- 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
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
- 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
- Experience with EZCap (preferred)
- Experience in a delegated MSO or health plan environment (preferred)
- Certified Case Manager (CCM) preferred
