Utilization Management Review Nurse

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 Location Huntington Beach Office - Huntington Beach, CA Remote Type Fully Remote Position Type Full Time Description 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.

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