Review and process prior authorizations for outpatient services, procedures, referrals, and DME.
Evaluate requests using MCG guidelines and health plan criteria.
Review medical records to ensure completeness and medical necessity per guidelines.
Identify missing documentation and coordinate with providers for additional information.
Route denials to Medical Director and prepare clinical summaries when needed.
Document authorization activities in EZCap with notes and rationale.

🎯 Requirements

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
Experience with EZCap (preferred)
Knowledge of California managed care regulations (DMHC/CMS)

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