Registered Nurse (RN), Home Health Utilization Management

TL;DR

Registered Nurse (RN), Home Health Utilization Management: Review and authorize Home Health prior authorization requests using CMS regulations with an accent on medical necessity determinations, timely utilization management reviews, and evidence-based escalation. Focus on building documentation-driven decisions, maintaining accurate EMR/utilization management records, and collaborating with providers and care teams in a fast-paced remote environment.

Location: Remote - USA

Salary: $92,300 - $120,000 USD

Company

hirify.global provides data- and technology-enabled healthcare plans for America’s seniors.

What you will do

• Review Home Health prior authorization requests for medical necessity using CMS regulations, Medicare Benefit Policy Manual, and NCD/LCD.
• Conduct initial and concurrent clinical reviews to ensure appropriate, medically necessary care in the least restrictive setting.
• Complete utilization management reviews on time in line with CMS requirements, regulatory standards, and Clover policies.
• Collaborate with home health agencies, physicians, case managers, and internal care management teams to obtain required clinical documentation.
• Optimize care plans by identifying opportunities for appropriate utilization and escalating to Medical Directors when needed.
• Maintain accurate documentation in utilization management platforms and electronic medical records; support quality improvement and calibration sessions.

Requirements

• Compact RN license (current and valid).
• At least 3 years of recent clinical nursing experience, including Home Health, Case Management, Utilization Management, or Medicare Advantage.
• At least 1 year of experience performing medical necessity reviews using CMS criteria.
• Strong knowledge of the Medicare Benefit Policy Manual, CMS regulations, and National and Local Coverage Determinations (NCD/LCD).
• Excellent written and verbal communication skills with providers and interdisciplinary teams.
• Comfort working independently in a remote environment; experience with electronic medical records and utilization management systems.

Culture & Benefits

• Remote-first culture with flexibility (including No-Meeting Fridays and monthly company holidays).
• Comprehensive medical, dental, and vision coverage.
• Performance-based bonus program, 401k matching, and regular compensation reviews.
• Professional development funding, learning programs, mentorship, and ongoing performance feedback.
• Employee Stock Purchase Plan (ESPP), reimbursement for office setup expenses, and monthly cell phone & internet stipend.
• Paid parental leave for all new parents.

Hiring process

• Onboarding and training on Clover utilization management systems, workflows, and Home Health clinical guidelines.
• Progression to independent Home Health authorization reviews with ongoing quality, productivity, and turnaround time expectations.
• Ongoing calibration sessions, education, and quality improvement participation.