Clinical Review Nurse - Complex Case Management and Prior-Authorization

Key Responsibilities

The Clinical Review Nurse is responsible for processing prior authorization requests to ensure medical necessity and compliance with regulatory standards. Additionally, the role involves supporting complex case management and coordinating care for high-risk members within a managed care environment.

Requirements

Candidates must hold an active California RN license and possess 3-5 years of experience in clinical utilization management. Proficiency in MCG criteria, prior authorization workflows, and knowledge of California managed care regulations are required.

Qualifications

Experience

2+ years of experience

Key Skills