Clover Health
501 - 1000 employees
🏥 Healthcare
🛡️ Insurance
🤖 Artificial Intelligence
Healthcare • Insurance • Artificial Intelligence
Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.
Registered Nurse, Lead – Home Health Utilization Management
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Clover Health
501 - 1000 employees
🏥 Healthcare
🛡️ Insurance
🤖 Artificial Intelligence
Healthcare • Insurance • Artificial Intelligence
Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.
📋 Description
• Review Home Health prior authorization requests using CMS regulations, Medicare Benefit Policy, NCD/LCD criteria, and Clover guidelines • Complete initial and concurrent medical necessity reviews for Home Health services • Maintain an active review workload while meeting quality, productivity, and turnaround expectations • Apply clinical judgment and escalate complex cases to Medical Directors • Collaborate with providers, home health agencies, case managers, and internal teams to obtain clinical documentation • Document determinations in utilization management systems and electronic medical records • Identify opportunities to optimize care and appropriate Home Health utilization • Provide day-to-day clinical leadership and support to the Home Health UM nursing team • Serve as the primary resource for complex cases, CMS policy interpretation, and clinical guidance • Conduct quality audits and reviewer calibration • Perform monthly quality reviews and maintain greater than 90% reviewer concordance • Monitor productivity, quality, turnaround times, and workload distribution • Identify utilization trends, perform root cause analyses, and implement process improvements • Mentor and coach reviewing nurses • Train reviewers on episodic and per-visit Home Health authorization methodologies • Support onboarding, competency validation, and ongoing staff education • Partner with Home Health agencies to review utilization trends and strengthen collaboration • Work with Contracting to evaluate agency performance and support a high-quality provider network • Collaborate with cross-functional partners to improve workflows, consistency, and member outcomes • Support implementation of new CMS guidance, internal policies, and UM initiatives • Serve as the clinical escalation point before Medical Director review • Foster a collaborative, accountable, and high-performing team culture
🎯 Requirements
• 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) • 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 (preferred) • Organized and analytical, with ability to balance leadership and direct clinical review responsibilities • Proficiency with electronic medical records and utilization management systems • Ability to work collaboratively in a fast-paced environment focused on member outcomes
🏖️ Benefits
• Competitive base salary • Equity opportunities • Performance-based bonus program • 401(k) matching • Regular compensation reviews • Comprehensive medical, dental, and vision coverage • No-Meeting Fridays • Monthly company holidays • Mental health resources • Generous flexible time-off policy • Remote-first culture • Learning programs • Mentorship • Professional development funding • Regular performance feedback and reviews • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Collaboration with global teams • Paid parental leave for all new parents
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