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Utilization Management, Registered Nurse (RN) Remote - USA 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.

Responsibilities 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 Qualifications Hold a current and valid Compact Registered Nurse (RN) license (required) Experience in Utilization Management—Prior Authorization Reviews (required) At least 1 year of experience performing medical necessity reviews using CMS Medicare criteria (required) Strong knowledge of CMS guidelines, NCD/LCD and evidence‐based criteria (MCG, Interqual) Comfortable working in a remote, fast‐paced, and data‐driven environment with productivity standards Excellent interpersonal skills and ability to communicate with patients and colleagues Benefits Overview Financial Well-Being : Competitive base salary and equity opportunities, performance‐based bonus program, 401(k) matching, and regular compensation reviews Physical Well-Being : Comprehensive medical, dental, and vision coverage for employees and families Mental Well-Being : Initiatives such as No‐Meeting Fridays, monthly company holidays, access to mental health resources, generous flexible time‐off policy, and a remote‐first culture Professional Development : Learning programs, mentorship, professional development funding, and regular performance feedback and reviews 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 with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission‐driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare. Equal Opportunity Employer From Clover's inception, Diversity & Inclusion have always been key to our success.

We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one's identity. All of our employee's points of view are key to our success, and inclusion is everyone's responsibility.

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