Utilization Management Nurse I, RN

Clever Care Health Plan • Huntington Beach, CA

3d • $72,758 - $89,128 • Hybrid

About The Position

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

This position is based at the Huntington Beach office, with a hybrid schedule requiring three days onsite at the Huntington Beach or Monrovia office. Work is performed in an office environment and/or remotely, with frequent contact with staff and the public. Occasional irregular hours may be required based on business needs. Travel may be needed or required.

The posted salary range is $72,758 to $89,128 per year. A background check is required.

Requirements

• Active, unrestricted RN license.
• Minimum of three years of clinical experience.
• Knowledge of medical necessity criteria such as MCG or InterQual.
• Understanding of CMS and state utilization management regulations.
• Strong clinical assessment and documentation skills.
• Ability to manage a caseload efficiently.
• Effective provider communication.
• Ability to travel when needed or required.
• Ability to operate a keyboard, mouse, and phone; perform repetitive keyboarding and note-taking; sit for long periods; stand, reach, bend, and lift up to 15 pounds.
• Ability to express or exchange ideas, impart information to the public, and convey detailed instructions to staff accurately and quickly.

Nice To Haves

• At least one year of utilization management or case management experience.
• Bilingual proficiency in Cantonese, Mandarin, Spanish, Vietnamese, or Korean.

Responsibilities

• Conduct clinical review of prior authorization requests using approved criteria such as MCG and InterQual.
• Review outpatient and routine inpatient requests.
• Ensure compliance with CMS, state, and contractual turnaround-time requirements and regulatory timelines.
• 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.
• Support audit readiness and documentation integrity.
• Perform additional duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed