Utilization Management Nurse Jobs

About The Position

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.

Benefits

• Competitive base salary
• Equity opportunities
• Performance-based bonus program
• 401k matching
• Regular compensation reviews
• Comprehensive medical coverage
• Dental coverage
• Vision coverage
• No-Meeting Fridays
• Monthly company holidays
• Access to mental health resources
• Generous flexible time-off policy
• Remote-first culture
• Learning programs
• Mentorship
• Professional development funding
• Regular performance feedback and reviews
• Employee Stock Purchase Plan (ESPP)
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Paid parental leave