Clinical Review Nurse - Prior Authorization

Location: Chino, California, United States

Salary: $62,400–$93,600 USD per year

Company

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

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, facilities, Medical Directors, and operational teams to obtain information and communicate authorization decisions.
• Route cases requiring denial or additional clinical review to the Medical Director and prepare concise clinical summaries.
• Document authorization activities, decision rationale, status updates, and determinations accurately in EZCap.
• Support complex case management through assessments, care coordination, medication reviews, member outreach, and patient-centered care plans.

Requirements

• Active California RN license required.
• 3–5+ years of current clinical utilization management review experience.
• Prior authorization experience in a managed care or delegated environment.
• Experience with complex case management and knowledge of MCG criteria, medical necessity review, and authorization workflows.
• Knowledge of California managed care regulations, including DMHC and CMS requirements.
• Strong clinical assessment, communication, organization, and prioritization skills.

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 across UM Coordination, Claims, Eligibility, Operations, provider, and Medical Director functions.
• Contribute to scaling an AI-powered clinical care platform and risk-bearing care models.
• Employment is offered by hirify.global, Inc., an equal opportunity employer.