Utilization Management Review Nurse

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.  

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

Functions & Job Responsibilities

• May provide any of the following in support of medical claims reviews, appeal reviews, and utilization review practices.
• Completes medical necessity reviews for requested services using clinical judgment and refers cases to Medical Directors when needed
• Educate providers on utilization and medical management processes
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff
• Enter and maintain pertinent clinical information in various medical management systems
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• Conducts research necessary to make thorough/accurate basis for each determination made
• Work on special projects related to utilization management as needed
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations
• Audit case reviews to ensure compliance with utilization management policies and procedures
• Assist with the development of utilization management workflows, policies, and procedures
• Participates in all required training
• Assist with training for new hires and continued development of existing staff
• Serve as a back up to direct manager as needed
• Participate in daily census review process and productivity review for staff.
• Other duties as assigned

Qualifications

Education and Experience:

• Graduate from an Accredited School of Nursing.
• Bachelor’s degree in nursing preferred.
• Active state’s LPN/LVN or RN license.
• Three (3) years of utilization review experience in a Health Plan, IPA, or MSO.
• Two (2) years of clinical nursing experience
• Knowledge of utilization management principles and healthcare managed care.
• Experience with medical decision support tools (i.e. InterQual, MCG, NCD) and government sponsored managed care programs.
• Utilization management is a 24/7 operation. Generally, work hours are 8:00am – 5:00pm PST. Work schedules could also include rotations for holidays and weekends.

Skills:

• Strong organizational, task prioritization and delegation skills.
• 2-3 years of experience using Windows-based programs and MS Office suite, including creating spreadsheets and pivot tables in Excel, presentations in PowerPoint, and documents in Word
• Knowledge of required regulatory timelines to ensure department compliance with State and other regulatory contracts.
• Knowledge of basic computer applications with ability to adapt to new software programs.
• Excellent communication and people skills.
• Excellent typing skills.
• Strong writing skills.

Wage Range: $70,000/year - $90,000/year

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 prolonged 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 the public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.