Utilization Management Nurse I, RN

Clever Care Health PlanHuntington Beach, CA

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Overview

Schedule

Full-time

Career level

Senior-level

Remote

On-site

Job Description

Remote in California only

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The UM Nurse I - RN performs clinical review of authorization requests to determine medical necessity based on established criteria, regulatory requirements, and organizational policies. This role conducts utilization review activities under established guidelines and escalates complex or non-standard determinations to senior staff or the Medical Director.

Functions & Job Responsibilities

Conduct clinical review of prior authorization requests using approved criteria (e.g., MCG, InterQual).
Review outpatient and routine inpatient requests.
Ensure compliance with CMS, state, and contractual turnaround time requirements.
Document medical necessity determinations clearly and accurately.
Communicate authorization decisions to providers, members and internal teams.
Identify cases requiring physician or Medical Director review.
Participate in concurrent review and discharge planning coordination as assigned.
Ensure compliance with regulatory timelines.
Support audit readiness and documentation integrity.
Additional duties as assigned.

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FAQs About Utilization Management Nurse I, RN Jobs at Clever Care Health Plan

What is the work location for this position at Clever Care Health Plan?

This job at Clever Care Health Plan is located in Huntington Beach, CA, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.

What pay range can candidates expect for this role at Clever Care Health Plan?

Employer has not shared pay details for this role.

What employment applies to this position at Clever Care Health Plan?

Clever Care Health Plan lists this role as a Full-time position.

What experience level is required for this role at Clever Care Health Plan?

Clever Care Health Plan is looking for a candidate with "Senior-level" experience level.

What is the process to apply for this position at Clever Care Health Plan?

You can apply for this role at Clever Care Health Plan either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.