Registered Nurse (RN) Lead, Home Health Utilization Management

Clover Health
United States
Workplace: RemoteFull timeUSD 130,800 - 170,000 annuallyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 5+ yearsSkills: ["Organized","Analytical","Comfortable balancing leadership with direct clinical review","Clinical judgment","Collaboration"]

Lead Home Health utilization management by splitting your time between clinical authorization reviews and day-to-day nursing team leadership. Make timely, medically necessary determinations using CMS regulations, Medicare Benefit Policy, NCD/LCD criteria, and Clover guidelines. Provide clinical escalation support, conduct quality audits and reviewer calibration, coach reviewers, analyze utilization trends, and partner with Medical Directors, Quality, Operations, Contracting, and home health agencies to drive consistency, compliance, and continuous improvement.

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FursaFursa
Clover Health
Clover Health
1 day ago

Registered Nurse (RN) Lead, Home Health Utilization Management

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Source: Company careers pageValidated by: Fursa AI
Last checked: 7 hours agoStatus: Live

Job Summary

Lead Home Health utilization management by splitting your time between clinical authorization reviews and day-to-day nursing team leadership. Make timely, medically necessary determinations using CMS regulations, Medicare Benefit Policy, NCD/LCD criteria, and Clover guidelines. Provide clinical escalation support, conduct quality audits and reviewer calibration, coach reviewers, analyze utilization trends, and partner with Medical Directors, Quality, Operations, Contracting, and home health agencies to drive consistency, compliance, and continuous improvement.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Manager level

Key Responsibilities

  • •Conduct home health prior authorization reviews using CMS regulations, Medicare Benefit Policy, NCD/LCD criteria, and Clover guidelines.
  • •Complete initial and concurrent medical necessity reviews while maintaining quality, productivity, and turnaround expectations.
  • •Provide day-to-day clinical leadership for the Home Health UM nursing team, serving as escalation point for complex cases and CMS policy interpretation.
  • •Perform quality audits and reviewer calibration, including monthly quality reviews and maintaining greater than 90% reviewer concordance.
  • •Monitor productivity/quality/turnaround, identify utilization trends, perform root cause analyses, and implement process improvements while partnering with cross-functional stakeholders and home health agencies.

Pay and Benefits

Salary: USD 130,800 - 170,000 annually
Equity and Bonus:Equity
Perks:Health InsuranceDentalVision401k MatchingPaid LeavePaid ParentalLearning Budget

Key Requirements

  • •Hold a 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).
  • •2+ years of experience leading, mentoring, coaching, or developing clinical staff (preferred).
  • •Expertise in CMS regulations, the Medicare Benefit Policy Manual, and NCD/LCD criteria; experience with quality reviews, performance calibration, or clinical education is preferred.
Experience:5+ yearsHome HealthUtilization ManagementCase ManagementMedicare Advantage
Skills:OrganizedAnalyticalComfortable balancing leadership with direct clinical reviewClinical judgmentCollaboration
Licenses:Compact Registered Nurse (RN) license
Tech Stack:Electronic medical recordsUtilization management systems

Company Brief

Clover Health
Clover Health is a technology-driven health insurance company offering Medicare Advantage plans that combine clinical care coordination, data analytics, and value-based care to improve outcomes and reduce costs for seniors.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: Jersey City, United States
Founded: 2014
WebsiteLinkedIn