Clover Health

Registered Nurse (RN), Home Health Utilization Management

Clover Health • $92K — $120K *
US-AnywhereRemote in United States
Healthcare
Less than 5 years of experience
4 days ago
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • Must hold a current and valid Compact Registered Nurse (RN) license.
  • Minimum of 3 years recent clinical nursing experience including Home Health, Case Management, or Utilization Management.
  • At least 1 year of experience with medical necessity reviews using CMS criteria.
  • Strong knowledge of the Medicare Benefit Policy Manual and CMS regulations.
  • Excellent written and verbal communication skills.
  • Highly organized and self-motivated, with the ability to work independently in a remote setting.
  • Experience with electronic medical records and utilization management systems.

Responsibilities

  • Review Home Health prior authorization requests for medical necessity according to CMS and Clover guidelines.
  • Perform initial and concurrent clinical reviews for Home Health services.
  • Ensure completion of utilization management reviews following CMS and regulatory standards.
  • Collaborate with health agencies and physicians to gather necessary clinical documentation.
  • Identify opportunities for optimizing care plans and appropriate service utilization.
  • Apply clinical judgment to inform decision-making and escalate issues to Medical Directors as needed.
  • Maintain accurate documentation in utilization management platforms.

Benefits

  • Comprehensive medical, dental, and vision coverage for employees and families.
  • 401k matching and performance-based bonus programs available.
  • Flexible time-off policy and mental health resources to support well-being.
  • Professional development funding, mentorship programs, and regular feedback opportunities.
  • Employee Stock Purchase Plan (ESPP) for equity options.
Full Job Description
As a Registered Nurse (RN), Home Health Utilization Management, you will:
  • 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.

Success in this role looks like:
  • 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.

You should get in touch if you:
  • 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, accountability, and a commitment to continuous improvement.
  • Thrive in a collaborative, fast-paced environment focused on delivering exceptional member outcomes.

Benefits Overview:
  • Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
  • Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
  • Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
  • Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.

Additional Perks:
  • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
  • Reimbursement for office setup expenses
  • Monthly cell phone & internet stipend
  • Remote-first culture, enabling collaboration with global teams
  • Paid parental leave for all new parents
  • And much more!

$92,300-$120,000 USD

About Clover Health

Clover Health is a healthcare technology company that uses data and technology to improve medical outcomes and lower costs for patients. The company offers Medicare Advantage plans in select states, and uses its proprietary software platform to identify patients who are at risk of hospitalization or other adverse health outcomes. Clover Health also partners with healthcare providers to offer in-home primary care services to its members. The company was founded in 2014 and is headquartered in New York City.
Learn more about Clover Health
Size
1,760 employees
Industry
Healthcare
Founded
2013
* Ladders Estimates

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