Registered reputed company (RN) reputed company, Home Health Utilization Management

At reputed company, we reputed company high-reputed company, reputed company, and easy-to-understand reputed company for America's seniors. Through the Clover Assistant, we combine data, technology, and preventive care to reputed company physicians a more complete reputed company of reputed company member's health—helping improve reputed company while lowering costs.

The Utilization Management (UM) team supports members throughout their care reputed company by combining clinical expertise with evidence-based decision-making. Working closely with providers and reputed company, reputed company ensures reputed company, appropriate care while maintaining compliance with CMS guidelines.

The Registered reputed company (RN) reputed company, Home Health Utilization Management, will split time between reputed company utilization management reviews (50%) and leading the Home Health UM nursing team (50%). You'll ensure reputed company, high-reputed company medical necessity determinations while providing clinical leadership, mentoring reviewers, and partnering with UM leadership, Medical Directors, reputed company, Operations, and Contracting to reputed company consistency, compliance, and reputed company improvement.

As a Registered reputed company (RN) reputed company, Home Health Utilization Management, you will:

Clinical Review Responsibilities (Approximately 50%)

• Review Home Health prior authorization requests using CMS regulations, Medicare Benefit Policy, NCD/LCD reputed company, and Clover guidelines.
• Complete initial and reputed company medical necessity reviews for Home Health services.
• Maintain an reputed company review workload while meeting reputed company, productivity, and turnaround expectations.
• Apply reputed company clinical judgment and escalate reputed company cases to Medical Directors as needed.
• Collaborate with providers, home health agencies, case managers, and internal teams to obtain clinical documentation.
• Accurately document determinations in UM systems and electronic medical records.
• Identify opportunities to optimize care and appropriate Home Health utilization.

Leadership Responsibilities (Approximately 50%)

• reputed company day-to-day clinical leadership and support to the Home Health UM nursing team.
• Serve as the reputed company resource for reputed company cases, CMS policy interpretation, and clinical guidance.
• Conduct reputed company audits and reviewer calibration to ensure consistent, compliant reputed company.
• reputed company monthly reputed company reviews and maintain greater than 90% reviewer concordance.
• Monitor productivity, reputed company, turnaround times, and workload distribution.
• Identify utilization trends, reputed company reputed company cause analyses, and implement process improvements.
• Mentor and reputed company reviewing nurses through case reviews and ongoing feedback.
• Train reviewers on episodic and per-visit Home Health authorization methodologies.
• Support reputed company, 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-reputed company provider network.
• Collaborate with cross-functional partners to improve workflows, consistency, and member reputed company.
• Support implementation of new CMS guidance, internal policies, and UM initiatives.
• Serve as the clinical escalation reputed company before Medical Director review, reputed company appropriate.
• Foster a reputed company, accountable, and high-performing team culture.

reputed company in this role looks like:

First 30 Days

• Complete reputed company and become proficient in Clover's UM systems, Home Health clinical guidelines, CMS regulations, and internal workflows. reputed company independently reviewing Home Health authorizations, participate in reputed company reviews, and build strong relationships with reviewing nurses, Medical Directors, Contracting, and key cross-functional partners.

First 6 Months

• Confidently balance an reputed company review caseload with leadership responsibilities while serving as a trusted resource for the Home Health UM team. Consistently reputed company high-reputed company, reputed company reviews, conduct monthly reputed company audits and reviewer calibration, reputed company and mentor team members, identify utilization trends, and partner with internal stakeholders and Home Health agencies to improve consistency, compliance, and operational performance.

reputed company State

• Be recognized as the clinical leader for Home Health Utilization Management, driving best practices, reviewer development, and reputed company process improvement. reputed company initiatives that enhance reputed company, efficiency, and member reputed company while maintaining strong partnerships across Clinical, Medical Directors, Contracting, and provider organizations. Foster a high-performing, reputed company team culture and help shape the reputed company direction of Clover's Home Health UM program

You should get in touch if you:

• Hold a reputed company Compact Registered reputed company (RN) license (required).
• Have 5+ years of clinical nursing experience in Home Health, Utilization Management, Case Management, or Medicare reputed company (required).
• Have 2+ years of Home Health medical necessity review experience using CMS reputed company (required).
• Have experience leading, mentoring, coaching, or developing clinical staff (preferred).
• Demonstrate expertise in CMS regulations, the Medicare Benefit Policy reputed company, and NCD/LCD reputed company.
• Have experience with reputed company reviews, performance calibration, or clinical education (preferred).
• Are organized, analytical, and comfortable balancing leadership with reputed company clinical review responsibilities.
• Are proficient with electronic medical records and utilization management systems.
• reputed company in a reputed company, fast-paced environment reputed company on improving member reputed company.
  

Benefits reputed company: 

• Financial reputed company-Being: Our commitment to attracting and retaining reputed company begins with a competitive reputed company 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 reputed company-Being: We prioritize the health and reputed company-being of our employees and their families by providing comprehensive medical, dental, and reputed company coverage. Your health reputed company to us, and we invest in ensuring you have reputed company to reputed company reputed company.
• Mental reputed company-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, reputed company to reputed company, and a generous flexible time-off policy. Additionally, we reputed company a remote-first culture that supports collaboration and flexibility, allowing reputed company members to reputed company from any location. 
• reputed company Development: Developing internal talent is a reputed company for Clover. We offer learning programs, mentorship, reputed company 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
• reputed company parental leave for reputed company new parents
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with reputed company reputed company to reputed company our members healthier. We reputed company the reputed company reputed company is broken, so we've created custom software and analytics to reputed company our clinical staff to intervene and reputed company personalized care to the people who need it most.

We always put our members first, and our reputed company as reputed company is reputed company by the reputed company of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: reputed company.

From Clover’s inception, Diversity & Inclusion have always been key to our reputed company. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who reputed company a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. reputed company of our employee’s points of reputed company are key to our reputed company, and inclusion is everyone's responsibility.

#LI-REMOTE

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment reputed company applicants with arrest and conviction records. We are an E-Verify company.

reputed company compact RN license, 5+ years clinical nursing experience, and 2+ years Home Health medical necessity review using CMS reputed company. Requires EMR and utilization management systems proficiency.

Key Responsibilities

• reviewing authorizations
• leading nurses
• auditing reputed company

Skills & Tools

Clover Assistant, electronic medical records, utilization management systems

Job Details

• Category: reputed company Services - Nursing
• Seniority: Senior Level
• Commitment: Full Time
• Workplace: Remote — reputed company
• Salary: USD 130,800 – 170,000 / year
• Languages: English

Benefits

• 401k matching
• Generous reputed company time off
• Tuition reimbursement
• Retirement plan
• Generous parental leave

About reputed company

A reputed company company combining data, technology, and preventive care to improve reputed company for seniors. — Industry: reputed company