Registered Nurse (RN) Lead, Home Health Utilization Management

Clover Health

2d•$130,800 - $170,000•Remote

About The Position

The Registered Nurse (RN) Lead, Home Health Utilization Management, will split time between direct utilization management reviews (50%) and leading the Home Health UM nursing team (50%). You'll ensure timely, high-quality medical necessity determinations while providing clinical leadership, mentoring reviewers, and partnering with UM leadership, Medical Directors, Quality, Operations, and Contracting to drive consistency, compliance, and continuous improvement.

Requirements

Hold a current Compact Registered Nurse (RN) license (required).
Have 5+ years of clinical nursing experience in Home Health, Utilization Management, Case Management, or Medicare Advantage (required).
Have 2+ years of Home Health medical necessity review experience using CMS criteria (required).
Demonstrate expertise in CMS regulations, the Medicare Benefit Policy Manual, and NCD/LCD criteria.
Are proficient with electronic medical records and utilization management systems.

Nice To Haves

Have experience leading, mentoring, coaching, or developing clinical staff (preferred).
Have experience with quality reviews, performance calibration, or clinical education (preferred).
Are organized, analytical, and comfortable balancing leadership with direct clinical review responsibilities.
Thrive in a collaborative, fast-paced environment focused on improving member outcomes.

Responsibilities

Review Home Health prior authorization requests using CMS regulations, Medicare Benefit Policy, NCD/LCD criteria, and Clover guidelines.
Complete initial and concurrent medical necessity reviews for Home Health services.
Maintain an active review workload while meeting quality, productivity, and turnaround expectations.
Apply sound clinical judgment and escalate complex cases to Medical Directors as needed.
Collaborate with providers, home health agencies, case managers, and internal teams to obtain clinical documentation.
Accurately document determinations in UM systems and electronic medical records.
Identify opportunities to optimize care and appropriate Home Health utilization.
Provide day-to-day clinical leadership and support to the Home Health UM nursing team.
Serve as the primary resource for complex cases, CMS policy interpretation, and clinical guidance.
Conduct quality audits and reviewer calibration to ensure consistent, compliant decisions.
Perform monthly quality reviews and maintain greater than 90% reviewer concordance.
Monitor productivity, quality, turnaround times, and workload distribution.
Identify utilization trends, perform root cause analyses, and implement process improvements.
Mentor and coach reviewing nurses through case reviews and ongoing feedback.
Train reviewers on episodic and per-visit Home Health authorization methodologies.
Support onboarding, competency validation, and ongoing staff education.
Partner with Home Health agencies to review utilization trends and strengthen collaboration.
Work with Contracting to evaluate agency performance and support a high-quality provider network.
Collaborate with cross-functional partners to improve workflows, consistency, and member outcomes.
Support implementation of new CMS guidance, internal policies, and UM initiatives.
Serve as the clinical escalation point before Medical Director review, when appropriate.
Foster a collaborative, accountable, and high-performing team culture.