Registered Nurse (RN), Home Health Utilization Management

Clover Health

3h•$92,300 - $120,000•Remote

About The Position

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 Registered Nurse (RN), Home Health Utilization Management, you will: Review Home Health prior authorization requests for medical necessity using CMS regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines. Perform initial and concurrent clinical reviews for Home Health services, ensuring members receive appropriate, medically necessary care in the least restrictive setting. Ensure timely completion of utilization management reviews in accordance with CMS requirements, regulatory standards, and Clover policies. Collaborate with home health agencies, physicians, case managers, and internal care management teams to obtain clinical documentation needed for accurate determinations. 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 and appropriate escalation to Medical Directors when necessary. Maintain accurate and timely documentation within utilization management platforms and electronic medical records. Build collaborative relationships with provider partners to facilitate timely authorizations and positive member experiences. Maintain productivity, quality, and turnaround time expectations while managing multiple priorities in a fast-paced remote environment. Participate in quality improvement initiatives, calibration sessions, and ongoing education related to CMS regulations and utilization management best practices.

Requirements

Current and valid Compact Registered Nurse (RN) license (required).
At least 3 years of recent clinical nursing experience, including Home Health, Case Management, Utilization Management, or Medicare Advantage (required).
At least 1 year of experience performing medical necessity reviews using CMS criteria (required).
Strong knowledge of the Medicare Benefit Policy Manual, CMS regulations, and National and Local Coverage Determinations (NCD/LCD).
Excellent written and verbal communication skills with providers and interdisciplinary teams.
Highly organized, self-motivated, and comfortable working independently in a remote environment.
Experience navigating electronic medical records and utilization management systems.
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.

Responsibilities

Review Home Health prior authorization requests for medical necessity using CMS regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines.
Perform initial and concurrent clinical reviews for Home Health services, ensuring members receive appropriate, medically necessary care in the least restrictive setting.
Ensure timely completion of utilization management reviews in accordance with CMS requirements, regulatory standards, and Clover policies.
Collaborate with home health agencies, physicians, case managers, and internal care management teams to obtain clinical documentation needed for accurate determinations.
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 and appropriate escalation to Medical Directors when necessary.
Maintain accurate and timely documentation within utilization management platforms and electronic medical records.
Build collaborative relationships with provider partners to facilitate timely authorizations and positive member experiences.
Maintain productivity, quality, and turnaround time expectations while managing multiple priorities in a fast-paced remote environment.
Participate in quality improvement initiatives, calibration sessions, and ongoing education related to CMS regulations and utilization management best practices.