Utilization Management, Registered Nurse (RN)

2 hours, 49 minutes ago
Full-time
Junior
Quality Assurance and Testing
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised

Description

  • Perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute, and outpatient services.
  • Apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support utilization decisions.
  • 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 activities, including case audits and peer reviews.
  • Use strong personal accountability and independent decision-making in day-to-day case management.

Requirements

  • Current and valid Compact Registered Nurse (RN) license.
  • Experience in Utilization Management and prior authorization reviews.
  • At least 1 year of experience performing medical necessity reviews using CMS Medicare criteria.
  • Strong knowledge of CMS guidelines, NCD/LCD policies, and evidence-based criteria such as MCG or InterQual.
  • Comfort working in a remote, fast-paced, data-driven environment with productivity standards.
  • Excellent interpersonal and communication skills for working with patients and colleagues.
  • Preferred: Experience in acute inpatient, SNF, IRF, LTACH, or outpatient utilization review.
  • Preferred: Ability to work independently and make sound clinical decisions.
  • Salary range of $90,000 to $106,000 USD.
  • Compensation may vary based on internal equity, market data, education, work experience, and certifications.

Benefits

  • Competitive base salary with equity opportunities.
  • Performance-based bonus program.
  • 401(k) matching.
  • Comprehensive medical, dental, and vision coverage.
  • Flexible time-off policy and monthly company holidays.
  • Remote-first culture with No-Meeting Fridays.
  • Mental health resources and work-life balance support.
  • Learning programs, mentorship, professional development funding, and paid parental leave.
  • Employee Stock Purchase Plan (ESPP).
  • Office setup reimbursement and monthly cell phone and internet stipend.

Interested in this position?

Apply directly on the company website

Apply Now

Similar Roles

Propulsion Technician II, Valves

Relativity Space 251-1K Aerospace & Defense

Relativity Space is hiring a Propulsion Technician to support assembly and testing of Aeon-R engine components and engines for the Terran R rocket program.

26 minutes ago

Inventory Specialist II, First Shift

Relativity Space 251-1K Aerospace & Defense

Relativity Space is hiring a Materials Management specialist to support inventory control, material movement, and shop operations for its Terran R reusable launch vehicle program.

ERP
1 hour, 58 minutes ago

Senior Mobility Specialist - Germany

Remote 251-1K Professional Services

Remote is hiring a Senior Mobility Specialist to support global immigration compliance, mobility operations, and cross-border employee transitions within its Onboarding and Mobility team.

2 hours, 4 minutes ago

Energy Efficiency Specialist

Resource Innovations 251-1K Renewable Electricity

Resource Innovations is hiring an Energy Efficiency Specialist in Salt Lake City to conduct inspections, ratings, and program support for utility rebate energy efficiency projects in newly constructed buildings and homes across Utah.

2 hours, 30 minutes ago

You're on a roll! Sign up now to keep applying.

Sign Up

Already have an account? Log in

Used by 14,729+ remote workers