Registered Nurse; RN), Home Health Utilization Management

Registered Nurse (RN), Home Health Utilization Management

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 supports Clover members throughout their care journey, combining clinical expertise with data-driven insights to support evidence-based decision‑making while ensuring smooth, efficient, and compliant care transitions.

• 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.

• First 90 Days:
  Complete onboarding and become proficient in Clover’s utilization management systems, workflows, and Home Health clinical guidelines. Successfully transition to independently reviewing Home Health authorization requests while consistently meeting quality, productivity, and turnaround time expectations.
• First 6 Months:
  Independently manage a full caseload, demonstrating sound clinical judgment and regulatory compliance. Build strong partnerships with providers and internal teams to support timely, appropriate care decisions while contributing to quality improvement initiatives and team collaboration.
• First Year:
  Be recognized as a trusted clinical partner who consistently delivers accurate, timely, and high‑quality utilization management decisions. Help drive continuous improvement by sharing knowledge, supporting team initiatives, and maintaining expertise in CMS regulations and Home Health best practices.

• 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,…