Registered Nurse, Home Health Utilization Management

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $92.3k - $120k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Clover Health (Nasdaq: CLOV) is a physician enablement company focused on seniors who have historically lacked access to affordable, high-quality healthcareWe aim to provide great care, in a sustainable way, by having a business model built around improving medical outcomes while lowering avoidable costs. We do this while taking a holistic approach to understanding the health needs and social risk factors of those under our care. This strategy is underpinned by our proprietary software platform, the Clover Assistant, which is designed to aggregate patient data from across the health ecosystem to support clinical decision-making by presenting physicians and other providers with real-time, personalized recommendations at the point of care.Making care more accessible is at the heart of our business, and we believe patients should have the freedom to choose their doctors. We offer affordable Medicare Advantage plans with extensive benefits, provide primary care physicians with the Clover Assistant, and also make comprehensive home-based care available via the Clover Home Care program.With our corporate headquarters in Nashville, Clover’s workforce is distributed around the U.S. and also includes a team of world-class technologists based in Hong Kong. We manage care for Medicare Advantage members in Alabama, Arizona, Georgia, Mississippi, New Jersey, Pennsylvania, South Carolina, Tennessee, and Texas.We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road.If you’re a passionate person and interested in changing healthcare for the better, then Clover Health may just be the place for you.

📋 Description

• Review Home Health prior authorization requests for medical necessity using CMS regulations, the Medicare Benefit Policy Manual, and Clover clinical guidelines • Perform initial and concurrent clinical reviews for Home Health services • Ensure timely completion of utilization management reviews in accordance with CMS requirements and Clover policies • Collaborate with home health agencies, physicians, case managers, and internal care management teams to obtain clinical documentation • 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 • Maintain accurate and timely documentation within utilization management platforms and electronic medical records • Build collaborative relationships with provider partners to facilitate timely authorizations • Maintain productivity and quality while managing multiple priorities in a fast-paced remote environment • Participate in quality improvement initiatives and ongoing education related to CMS regulations

🎯 Requirements

• 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

• Competitive base salary and equity opportunities • Performance-based bonus program • 401k matching • Comprehensive medical, dental, and vision coverage • No-Meeting Fridays, monthly company holidays, and access to mental health resources • Generous flexible time-off policy • Learning programs, mentorship, and professional development funding