Utilization Management Nurse I, RN

Job Summary

The UM Nurse I - RN at Clever Care 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.

Qualifications

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

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.