Operations Management Jobs 2026 (Now Hiring) – Smart Auto Apply

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.