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: Perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute (SNF, IRF, LTACH) and outpatient services Apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support determinations Manage cases end-to-end from prior authorization through concurrent review and discharge Collaborate with providers and facilities to obtain clinical information and support care coordination Ensure compliance with CMS turnaround times and regulatory requirements Participate in Quality Assurance (QA) activities, including case audits and peer reviews to ensure accuracy and consistency in decision-making Have strong personal accountability, responsibility and independent decision-making abilities. You should get in touch if: You hold a current and valid Compact Registered Nurse (RN) license (required). You have experience in Utilization Management - Prior Authorization Reviews (required). You have at least 1 year of experience performing medical necessity reviews using CMS Medicare criteria (required). You have strong knowledge of CMS guidelines, NCD/LCD and evidence based criteria (MCG, Interqual) You are comfortable working in a remote, fast-paced, and data-driven environment with productivity standards You have excellent interpersonal skills and ability to communicate with patients and colleagues. Benefits Overview : 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. 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. 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. Professional Development : Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews. Additional Perks: Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities Reimbursement for office setup expenses Monthly cell phone internet stipend Remote-first culture, enabling collaboration with global teams Paid parental leave for all new parents And much more! About Clover: We are reinventing health insurance by combining the power of data w ... (truncated, view full listing at source)