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Clinical Review Responsibilities:
- Review Home Health prior authorization requests using CMS guidelines and Clover criteria.
- Complete initial and concurrent medical necessity reviews.
- Accurately document determinations in UM systems.
Leadership Responsibilities:
- Provide clinical leadership and support to the UM nursing team.
- Conduct quality audits and reviewer calibration.
- Mentor and coach reviewing nurses.
Success in this role looks like:
- Complete onboarding and become proficient in Clover's UM systems.
- Balance an active review caseload with leadership duties.
- Be recognized as the clinical leader for Home Health UM.
Clover Health
Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.