Utilization Management, Registered Nurse (RN)

Clover Health

10h•Remote

About The Position

The Utilization Management (UM) team plays a vital role in supporting Clover members throughout their care journey. The team is made up of experienced clinicians who combine clinical expertise with data-driven insights to support evidence-based decision-making. Working closely with providers and care partners, the UM team ensures that care transitions are smooth, efficient, and always focused on improving member outcomes while maintaining compliance with CMS guidelines. As a Utilization Management, Registered Nurse (RN), you will perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute (SNF, IRF, LTACH) and outpatient services. You will apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support determinations. You will manage cases end-to-end from prior authorization through concurrent review and discharge. You will collaborate with providers and facilities to obtain clinical information and support care coordination, and ensure compliance with CMS turnaround times and regulatory requirements. You will also participate in Quality Assurance (QA) activities, including case audits and peer reviews to ensure accuracy and consistency in decision-making. You will have strong personal accountability, responsibility and independent decision-making abilities.

Requirements

Hold a current and valid Compact Registered Nurse (RN) license (required).
Experience in Utilization Management - Prior Authorization Reviews (required).
At least 1 year of experience performing medical necessity reviews using CMS Medicare criteria (required).
Strong knowledge of CMS guidelines, NCD/LCD and evidence based criteria (MCG, Interqual)
Comfortable working in a remote, fast-paced, and data-driven environment with productivity standards
Excellent interpersonal skills and ability to communicate with patients and colleagues.

Responsibilities

Perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute (SNF, IRF, LTACH) and outpatient services
Apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support determinations
Manage cases end-to-end from prior authorization through concurrent review and discharge
Collaborate with providers and facilities to obtain clinical information and support care coordination
Ensure compliance with CMS turnaround times and regulatory requirements
Participate in Quality Assurance (QA) activities, including case audits and peer reviews to ensure accuracy and consistency in decision-making
Have strong personal accountability, responsibility and independent decision-making abilities.