Remote in California only
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 UM Nurse II – RN performs advanced clinical review of complex authorization requests and serves as a clinical escalation point and resource for UM Nurse I staff. This role manages high-acuity, specialty, and escalated cases and supports compliance monitoring and workflow optimization initiatives.
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.
· Review high-complexity inpatient, specialty, or high-cost cases.
· Performs concurrent and retrospective reviews.
· Handle expedited and escalated determinations.
· Serve as subject matter expert for assigned service lines.
· Support regulatory compliance monitoring and quality audits.
· Assist in denial trend analysis and improvement initiatives.
· Mentor and guide UM Nurse I staff.
· Collaborate with Medical Director on complex determinations or high risk cases.
· Participate in workflow development and optimization.
· Additional duties as assigned.