Perform clinical reviews of authorization requests to determine medical necessity based on established criteria and regulatory requirements. Communicate decisions to providers and members while ensuring compliance with CMS and state turnaround times.
Requirements summary
Requires an active, unrestricted RN license and a minimum of three years of clinical experience. Preference is given to candidates with utilization management experience and bilingual proficiency in specific Asian or Romance languages.
Range: $34.98 - $42.85 HourlyRemote 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. QualificationsQualifications Education and Experience · Active, unrestricted RN license. · Minimum of three (3) years of clinical experience. · At least one (1) year in utilization management or case management preferred. Skills · Knowledge of medical necessity criteria (MCG/InterQual). · Understanding of CMS/state UM regulations. · Strong clinical assessment and documentation skills · Ability to manage caseload efficiently. · Effective provider communication. · Bilingual proficiency in Cantonese, Mandarin, Spanish, Vietnamese, or Korean preferred.
Wage
Range: $34.98 to $42.85 per hour Physical & Working Environment. Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
Must be able to travel when needed or required
Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs. Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business. Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency. #LI-Remote
