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Registered Nurse (RN) Lead, Home Health Utilization Management

20 hours, 13 minutes ago
United States
Full-time
Lead
Operations Manager
Operations
Apply Now
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised
View All Jobs 23

Description

  • 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 caseload while meeting quality, productivity, and turnaround expectations.
  • Escalate complex cases to Medical Directors and serve as the clinical escalation point when appropriate.
  • Collaborate with providers, home health agencies, case managers, and internal teams to obtain clinical documentation.
  • Document utilization management determinations accurately in UM systems and electronic medical records.
  • Provide day-to-day clinical leadership and support to the Home Health UM nursing team.
  • Conduct quality audits, reviewer calibration, and monthly quality reviews to ensure consistent, compliant decisions.
  • Monitor productivity, quality, turnaround times, and workload distribution.
  • Mentor, coach, train, and onboard reviewing nurses while supporting competency validation and ongoing staff education.
  • Identify utilization trends, perform root cause analyses, and implement process improvements.
  • Partner with Home Health agencies, Contracting, and cross-functional teams to improve workflows, consistency, and member outcomes.

Requirements

  • Current Compact Registered Nurse (RN) license required.
  • 5+ years of clinical nursing experience in Home Health, Utilization Management, Case Management, or Medicare Advantage required.
  • 2+ years of Home Health medical necessity review experience using CMS criteria required.
  • Experience leading, mentoring, coaching, or developing clinical staff preferred.
  • Strong expertise in CMS regulations, the Medicare Benefit Policy Manual, and NCD/LCD criteria.
  • Experience with quality reviews, performance calibration, or clinical education preferred.
  • Proficiency with electronic medical records and utilization management systems.
  • Strong organizational and analytical skills with the ability to balance leadership and direct review responsibilities.
  • Ability to thrive in a collaborative, fast-paced environment focused on improving member outcomes.

Benefits

  • Competitive base salary of $130,800 to $170,000 USD.
  • Equity opportunities, including Employee Stock Purchase Plan (ESPP).
  • Performance-based bonus program and 401(k) matching.
  • Comprehensive medical, dental, and vision coverage.
  • Flexible time-off policy, No-Meeting Fridays, and monthly company holidays.
  • Remote-first work culture.
  • Access to mental health resources.
  • Learning programs, mentorship, professional development funding, and regular feedback.
  • Office setup reimbursement and monthly cell phone and internet stipend.
  • Paid parental leave for all new parents.

Interested in this position?

Apply directly on the company website

Apply Now

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