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 H…