Utilization Management Nurse I, RN

Paycom; Huntington Beach, Arcadia (CA, CA); Hybrid; USD 73,000 - 89,000; Full time

Job summary

Clever Care Health Plan in Huntington Beach, CA, is seeking a UM Nurse I - RN to perform clinical reviews of authorization requests to determine medical necessity according to criteria and policies. The role conducts utilization review activities under established guidelines and escalates complex determinations to senior staff or the Medical Director, coordinating with providers and internal teams.

Hybrid work with 3 onsite days is required.

Qualifications

• Active, unrestricted RN license.
• 3+ years of clinical experience.
• 1+ year in utilization management or case management preferred.

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.
• Ensure compliance with regulatory timelines.
• Support audit readiness and documentation integrity.

Skills

Clinical review

Medical necessity criteria (MCG/InterQ

CMS/state UM regulations

Documentation skills

Caseload management

Provider communication

Bilingual (Cantonese, Mandarin, etc.)

Education

RN license (active, unrestricted)

3+ years clinical experience

1+ year in UM or case management

Job description

Job Details: Job Location: Huntington Beach Office - Huntington Beach, CA 92647, Position Type: Full Time, Salary Range: $72,758.00 - $89,128.00 Salary/year, This position operates on a hybrid work schedule. This position will require 3 days onsite at the Huntington Beach or Monrovia office.

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 I - RN performs clinical review of authorization requests to determine medical necessity based on established criteria, regulatory requirements, and organizational policies. This role conducts utilization review activities under established guidelines and escalates complex or non-standard determinations to senior staff or the Medical Director.

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.
• Ensure compliance with regulatory timelines.
• Support audit readiness and documentation integrity.
• Additional duties as assigned.

Qualification: Qualifications

Education and Experience

• Active, unrestricted RN license.
• Minimum of three (3) years of clinical experience.
• At least one (1) year in utilization management or case management preferred.

Skills

• Knowledge of medical necessity criteria (MCG/InterQual).
• Understanding of CMS/state UM regulations.
• Strong clinical assessment and documentation skills
• Ability to manage caseload efficiently.
• Effective provider communication.
• Bilingual proficiency in Cantonese, Mandarin, Spanish, Vietnamese, or Korean preferred.

Wage Range: $72,758/year to $89,128/year

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs. Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Aff …he.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.