Registered Nurse, Lead – Home Health Utilization Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate Home Health prior authorization requests in accordance with CMS regulations, Medicare Benefit Policy, NCD/LCD criteria, and Clover guidelines.

• Conduct initial and concurrent reviews of medical necessity for Home Health services.

• Manage an active review workload while achieving quality, productivity, and turnaround time goals.

• Utilize clinical judgment and escalate complicated cases to Medical Directors.

• Work together with providers, home health agencies, case managers, and internal teams to gather clinical documentation.

• Record determinations in utilization management systems and electronic medical records.

• Identify opportunities for optimizing care and ensuring appropriate Home Health utilization.

• Provide daily clinical leadership and support to the Home Health UM nursing team.

• Act as the primary resource for complex cases, CMS policy interpretation, and clinical advice.

• Conduct quality audits and reviewer calibration.

• Execute monthly quality reviews and maintain over 90% reviewer concordance.

• Monitor productivity, quality, turnaround times, and workload distribution.

• Identify trends in utilization, perform root cause analyses, and implement process improvements.

• Mentor and coach reviewing nurses.

• Train reviewers on episodic and per-visit Home Health authorization methodologies.

• Assist with onboarding, competency validation, and ongoing staff education.

• Collaborate with Home Health agencies to review utilization trends and enhance partnerships.

• Work with Contracting to assess agency performance and support a high-quality provider network.

• Collaborate with cross-functional partners to enhance workflows, consistency, and member outcomes.

• Support the implementation of new CMS guidance, internal policies, and UM initiatives.

• Serve as the clinical escalation contact prior to Medical Director review.

• Promote a collaborative, accountable, and high-performing team culture.

⛳️ Requirements

• Current Compact Registered Nurse (RN) license (mandatory).

• Over 5 years of clinical nursing experience in Home Health, Utilization Management, Case Management, or Medicare Advantage (mandatory).

• At least 2 years of experience in Home Health medical necessity review utilizing CMS criteria (mandatory).

• Experience in leading, mentoring, coaching, or developing clinical staff (preferred).

• In-depth knowledge of CMS regulations, the Medicare Benefit Policy Manual, and NCD/LCD criteria.

• Familiarity with quality reviews, performance calibration, or clinical education (preferred).

• Highly organized and analytical, capable of balancing leadership and direct clinical review duties.

• Proficient in using electronic medical records and utilization management systems.

• Ability to collaborate effectively in a fast-paced environment that prioritizes member outcomes.

🏝️ Benefits

• Competitive base salary.

• Equity opportunities.

• Performance-based bonus program.

• 401(k) matching.

• Regular compensation reviews.

• Comprehensive medical, dental, and vision coverage.

• No-Meeting Fridays.

• Monthly company holidays.

• Mental health resources.

• Generous flexible time-off policy.

• Remote-first culture.

• Learning programs.

• Mentorship.

• Professional development funding.

• Regular performance feedback and reviews.

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.

• Reimbursement for office setup expenses.

• Monthly cell phone & internet stipend.

• Collaboration with global teams.

• Paid parental leave for all new parents.