Utilization Management, Registered Nurse (rn)

Cloverhealth

Remote, United States
Base: $90,000 - $106,000 usd; bonus/equity: perfor...
Remote
Medical necessity reviews
Cms medicare guidelines application
Prior authorization experience
Clover Health is seeking a Utilization Management Registered Nurse (RN) to work remotely, focusing on medical necessity reviews and care coordination for seniors. The position requires experience in Utilization Management and knowledge of CMS guidelines, with a commitment to improving patient outcomes

Job Summary

  • The Utilization Management team supports Clover members by combining clinical expertise with data-driven insights to ensure evidence-based decision-making.
  • This role requires performing medical necessity reviews for prior authorization and concurrent review across various healthcare settings including acute inpatient and post-acute services.
  • Employees benefit from a remote-first culture, comprehensive health coverage, performance-based bonuses, and professional development funding.

Matching Summary

Match Score: 85

Clover Health is seeking a Utilization Management Registered Nurse (RN) to work remotely, focusing on medical necessity reviews and care coordination for seniors. The position requires experience in Utilization Management and knowledge of CMS guidelines, with a commitment to improving patient outcomes.

Salary

Base: $90,000 - $106,000 USD; Bonus/Equity: Performance-based bonus program and equity opportunities; Benefits: 401k matching, medical/dental/vision, ESPP

Skills & Requirements

Must-have

  • Medical necessity reviews
  • CMS Medicare guidelines application
  • Prior authorization experience
  • Concurrent case management
  • Provider collaboration skills

Nice-to-have

  • Remote work environment comfort
  • Data-driven decision making
  • Strong interpersonal communication
  • Quality assurance participation
  • Independent decision-making ability

Key Requirements

  • Current valid Compact RN license
  • Experience in utilization management prior authorization
  • 1 year experience with CMS Medicare criteria
  • Knowledge of NCD/LCD policies and MCG criteria

Work Rights

Must have US Compact RN license

Tailored Resume

Cover Letter