Registered Nurse (RN), Home Health Utilization Management

About the role

The Utilization Management (UM) team at Clover Health plays a vital role in supporting Clover members throughout their care journey. The team combines clinical expertise with data-driven insights to support evidence-based decision-making, ensuring that care transitions are smooth, efficient, and focused on improving member outcomes while maintaining compliance with CMS guidelines.

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.
• Manage multiple priorities in a fast-paced remote environment while maintaining productivity, quality, and turnaround time expectations.
• Participate in quality improvement initiatives, calibration sessions, and ongoing education related to CMS regulations and utilization management best practices.

Requirements

• A current and valid Compact Registered Nurse (RN) license.
• At least 3 years of recent clinical nursing experience, including Home Health, Case Management, Utilization Management, or Medicare Advantage.
• At least 1 year of experience performing medical necessity reviews using CMS criteria.
• 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.

Qualifications

• Passionate and mission-driven individuals with diverse areas of expertise.
• Collaborative and fast-paced environment focused on delivering exceptional member outcomes.

Skills

• Strong clinical judgment and regulatory compliance.
• Effective communication and collaboration skills.
• Ability to work independently in a remote environment.
• Knowledge of electronic medical records and utilization management systems.
• Commitment to continuous improvement and team collaboration.

Benefits

• Financial Well-Being: Competitive base salary, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and vision coverage.
• Mental Well-Being: No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.
• Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Additional Perks: Employee Stock Purchase Plan (ESPP), reimbursement for office setup expenses, monthly cell phone & internet stipend, remote-first culture, paid parental leave for all new parents, and much more!

About Clover

We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most. We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Diversity & Inclusion are key to our success, and we embrace a remote-first culture that supports collaboration and flexibility, enabling our team members to thrive from any location.

Company Information

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company. Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc. A reasonable estimate of the base salary range for this role is: $92,300—$120,000 USD.