Utilization Management, Registered Nurse (RN)

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most.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:<ul><li>Perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute (SNF, IRF, LTACH) and outpatient services</li><li>Apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support determinations</li><li>Manage cases end-to-end from prior authorization through concurrent review and discharge</li><li>Collaborate with providers and facilities to obtain clinical information and support care coordination</li><li>Ensure compliance with CMS turnaround times and regulatory requirements</li><li>Participate in Quality Assurance (QA) activities, including case audits and peer reviews to ensure accuracy and consistency in decision-making</li><li>Have strong personal accountability, responsibility and independent decision-making abilities.</li></ul>You should get in touch if:<ul><li>You hold a current and valid Compact Registered Nurse (RN) license (required).</li><li>You have experience in Utilization Management - Prior Authorization Reviews  (required).</li><li>You have at least 1 year of experience performing medical necessity reviews using CMS Medicare criteria (required).</li><li>You have strong knowledge of CMS guidelines,  NCD/LCD and evidence based criteria (MCG, Interqual)</li><li>You are comfortable working in a remote, fast-paced, and data-driven environment with productivity standards</li><li>You have excellent interpersonal skills and ability to communicate with patients and colleagues.</li></ul><hr>Benefits Overview:<ul><li>Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.</li><li>Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.</li><li>Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. </li><li>Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.</li></ul>Additional Perks:<ul><li>Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities</li><li>Reimbursement for office setup expenses</li><li>Monthly cell phone & internet stipend</li><li>Remote-first culture, enabling collaboration with global teams</li><li>Paid parental leave for all new parents</li><li>And much more!</li></ul><hr>About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.<hr>#LI-REMOTEPursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an<a href="https://e-verify.uscis.gov/esp/media/resourcesContents/E-Verify_Participation_Poster.pdf"> E-Verify</a> company.<div class="content-pay-transparency"><div class="pay-input"><div class="description">Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.</div><div class="title">A reasonable estimate of the base salary range for this role is:</div><div class="pay-range">$90,000—$106,000 USD</div></div></div>

Utilization Management, Registered Nurse (RN)

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