Registered Nurse (RN) Lead, Home Health Utilization Management

At Clover Health, we provide high-quality, affordable, and easy-to-understand healthcare for America's seniors. Through the Clover Assistant, we combine data, technology, and preventive care to give physicians a more complete view of each member's health—helping improve outcomes while lowering costs. The Utilization Management (UM) team supports members throughout their care journey by combining clinical expertise with evidence-based decision-making. Working closely with providers and care partners, the team ensures timely, appropriate care while maintaining compliance with CMS guidelines. The Registered Nurse (RN) Lead, Home Health Utilization Management, will split time between direct utilization management reviews (50%) and leading the Home Health UM nursing team (50%). You'll ensure timely, high-quality medical necessity determinations while providing clinical leadership, mentoring reviewers, and partnering with UM leadership, Medical Directors, Quality, Operations, and Contracting to drive consistency, compliance, and continuous improvement. As a Registered Nurse (RN) Lead, 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 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 sound clinical judgment and escalate complex 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%) 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 to ensure consistent, compliant decisions. 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 through case reviews and ongoing feedback. 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, when appropriate. Foster a collaborative, accountable, and high-performing team culture. Success in this role looks like: First 30 Days Complete onboarding and become proficient in Clover's UM systems, Home Health clinical guidelines, CMS regulations, and internal workflows. Begin independently reviewing Home Health authorizations, participate in quality reviews, and build strong relationships with reviewing nurses, Medical Directors, Contracting, and key cross-functional partners. First 6 Months Confidently balance an active review caseload with leadership responsibilities while serving as a trusted resource for the Home Health UM team. Consistently deliver high-quality, timely reviews, conduct monthly quality audits and reviewer calibration, coach and mentor team members, identify utilization trends, and partner with internal stakeholders and Home Health agencies to improve consistency, compliance, and operational performance. Future State Be recognized as the clinical leader for Home Health Utilization Management, driving best practices, reviewer development, and continuous process improvement. Lead initiatives that enhance quality, efficiency, and member outcomes while maintaining strong partnerships across Clinical, Medical Directors, Contracting, and provider organizations. Foster a high-performing, collaborative team culture and help shape the future direction of Clover's Home Health UM program You should get in touch if you: Hold a current Compact Registered Nurse (RN) license (required). Have 5+ years of clinical nursing experience in Home Health, Utilization Management, Case Management, or Medicare Advantage (required). Have 2+ years of Home Health medical necessity review experience using CMS criteria (required). Have experience leading, mentoring, coaching, or developing clinical staff (preferred). Demonstrate expertise in CMS regulations, the Medicare Benefit Policy Manual, and NCD/LCD criteria. Have experience with quality reviews, performance calibration, or clinical education (preferred). Are organized, analytical, and comfortable balancing leadership with direct clinical review responsibilities. Are proficient with electronic medical records and utilization management systems. Thrive in a collaborative, fast-paced environment focused on improving member outcomes. Benefits Overview : Financial Well-Being : Our commitment to attracting and retaining top talent begins with a competitive base 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 Well-Being : We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare. Mental Well-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, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. Professional Development : Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional 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 Paid parental leave for all new parents And much more! About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most. We always put our members first, and our success as a team is measured by the quality 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: healthcare. From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share 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. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility. #LI-REMOTE Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company. Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc. A reasonable estimate of the base salary range for this role is: $130,800 — $170,000 USD