Utilization Management Nurse I, RN

Clever Care Health Plan•Huntington Beach, CA

4d•Remote

About The Position

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.

Requirements

Active, unrestricted RN license.
Minimum of three (3) years of clinical experience.
At least one (1) year in utilization management or case management preferred.
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.

Nice To Haves

Bilingual proficiency in Cantonese, Mandarin, Spanish, Vietnamese, or Korean preferred.

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.