Clover Health logo
Clover Health

Clover is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans.

Registered Nurse, Home Health Utilization Management

GeneralGeneralFull TimeRemoteSeniorTeam 501-1,000H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

6 days ago

Salary

$92.3K - $120K / year

Seniority

Senior

Bachelor Degree3 yrs expEnglish

Job Description

Registered Nurse, Home Health Utilization Management

Clover Health

• Review Home Health prior authorization requests for medical necessity using CMS regulations, the Medicare Benefit Policy Manual, and Clover clinical guidelines • Perform initial and concurrent clinical reviews for Home Health services • Ensure timely completion of utilization management reviews in accordance with CMS requirements and Clover policies • Collaborate with home health agencies, physicians, case managers, and internal care management teams to obtain clinical documentation • Identify opportunities to optimize care plans while promoting appropriate utilization of Home Health services • Apply sound clinical judgment and critical thinking to support evidence-based decision-making • Maintain accurate and timely documentation within utilization management platforms and electronic medical records • Build collaborative relationships with provider partners to facilitate timely authorizations • Maintain productivity and quality while managing multiple priorities in a fast-paced remote environment • Participate in quality improvement initiatives and ongoing education related to CMS regulations

Job Requirements

  • Hold a current and valid Compact Registered Nurse (RN) license (required)
  • Have at least 3 years of recent clinical nursing experience, including Home Health, Case Management, Utilization Management, or Medicare Advantage (required)
  • Have at least 1 year of experience performing medical necessity reviews using CMS criteria (required)
  • Demonstrate strong knowledge of the Medicare Benefit Policy Manual, CMS regulations, and National and Local Coverage Determinations (NCD/LCD)
  • Possess excellent written and verbal communication skills with providers and interdisciplinary teams
  • Are highly organized, self-motivated, and comfortable working independently in a remote environment
  • Have experience navigating electronic medical records and utilization management systems
  • Are highly motivated and contribute to a positive, collaborative team culture while demonstrating professionalism, accountability, and a commitment to continuous improvement
  • Thrive in a collaborative, fast-paced environment focused on delivering exceptional member outcomes

Benefits

  • Competitive base salary and equity opportunities
  • Performance-based bonus program
  • 401k matching
  • Comprehensive medical, dental, and vision coverage
  • No-Meeting Fridays, monthly company holidays, and access to mental health resources
  • Generous flexible time-off policy
  • Learning programs, mentorship, and professional development funding

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