Clinical Review Nurse - Complex Case Management and Prior-Authorization

Location: Chino, California, United States

Salary: $78,000–$103,000 USD per year

Company

hirify.global is an AI-native care provider combining clinical technology with a nationwide medical network to deliver primary and specialty care and address physician shortages.

What you will do

• Review and process prior authorizations for outpatient services, procedures, diagnostic testing, specialty referrals, durable medical equipment, and ancillary services.
• Evaluate medical necessity and documentation using MCG guidelines, health plan criteria, and established clinical policies.
• Coordinate with providers, physicians, medical groups, facilities, and ancillary providers to obtain missing information and communicate authorization updates.
• Lead interdisciplinary case management for high-risk and medically or psychosocially complex populations, including comprehensive assessments, care plans, medication reviews, and monthly outreach.
• Prepare clinical summaries for Medical Director determinations and route cases requiring denial appropriately.
• Document authorization activity, decisions, care management work, and rationale accurately in EZCap while collaborating with UM Coordinators, Claims, Eligibility, and Operations.

Requirements

• Active California RN license required.
• 3–5+ years of current clinical utilization management review experience.
• Experience with prior authorization in a managed care or delegated environment.
• Experience with complex case management and strong clinical assessment skills.
• Knowledge of MCG criteria, medical necessity review, prior authorization workflows, and California DMHC/CMS managed care requirements.
• Strong written and verbal communication skills with the ability to manage competing priorities in a fast-paced environment.

Nice to have

• Experience with EZCap.
• Experience in a delegated MSO or health plan environment.
• Certified Case Manager (CCM) certification.

Culture & Benefits

• Work within a Utilization Management department supporting delegated operations in a California managed care environment.
• Collaborate with Medical Directors, providers, clinical teams, Claims, Eligibility, and Operations.
• Contribute to AI-enabled care delivery through Akido’s ScopeAI platform and medical network.
• Equal opportunity employment is offered to qualified applicants from all backgrounds and abilities.