Registered Nurse (RN), Home Health Utilization Management
New
C
Clover HealthHealthcare Insurance
Remote - USAFull-TimeMiddle
Salary$92,300 — $120,000 USD
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Job Details
- Experience
- 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.
Requirements
- Current and valid Compact Registered Nurse (RN) license.
- At least 3 years of recent clinical nursing experience (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.
- Experience navigating electronic medical records and utilization management systems.
- High level of organization and ability to work independently in a remote environment.
- Commitment to professionalism, accountability, and continuous improvement.
Responsibilities
- Review Home Health prior authorization requests for medical necessity using CMS regulations, NCD/LCD, and company clinical guidelines.
- Perform initial and concurrent clinical reviews for Home Health services to ensure medically necessary care in the least restrictive setting.
- Ensure timely completion of utilization management reviews in accordance with CMS requirements and company policies.
- Collaborate with home health agencies, physicians, and internal teams to obtain clinical documentation for accurate determinations.
- Identify opportunities to optimize care plans while promoting appropriate utilization of services.
- Apply clinical judgment and critical thinking to support evidence-based decisions and escalations to Medical Directors.
- Maintain accurate and timely documentation within utilization management platforms and electronic medical records.
- Build collaborative relationships with provider partners to facilitate timely authorizations.
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