Registered Nurse (RN), Home Health Utilization Management

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most. The Utilization Management (UM) team plays a vital role in supporting Clover members throughout their care journey. The team is made up of experienced clinicians who combine clinical expertise with data-driven insights to support evidence-based decision-making. Working closely with providers and care partners, the UM team ensures that care transitions are smooth, efficient, and always focused on improving member outcomes while maintaining compliance with CMS guidelines. As a Registered Nurse (RN), Home Health Utilization Management, you will: Review Home Health prior authorization requests for medical necessity using CMS regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines. Perform initial and concurrent clinical reviews for Home Health services, ensuring members receive appropriate, medically necessary care in the least res...