Registered Nurse (RN), Home Health Utilization Management

Responsibilities:

• Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
• Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
• Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.

Qualifications:

• Hold a current Compact Registered Nurse license and have at least 3 years of clinical nursing experience in Home Health, Utilization Management, or Medicare Advantage.
• Demonstrate strong knowledge of Medicare Benefit Policy Manual and CMS criteria.
• Possess excellent communication skills and thrive in a collaborative, remote environment.

Benefits:

• Comprehensive medical, dental, and vision coverage to support physical well-being.
• Generous flexible time-off policy and mental health resources including No-Meeting Fridays.
• Professional development opportunities, equity, and 401k matching.