UM Post-Acute SNF RN

At Clover Health we are committed to providing high-quality affordable and easy-to-understand healthcare plans for Americas 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 members complete health history we ensure better care at a lower costdelivering 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 UM Post-Acute SNF RN you will:

• Expertise in reviewing medical records of post-acute (SNF IRF LTACH) prior authorization reviews for medical necessity.
• Complete medical necessity review of post-acute (SNF IRF LTACH) facility prior authorization requests.
• Ensure timely reviews in accordance with CMS requirements and Clover policies and procedures.
• Manage assigned post-acute prior authorizations from initial review to concurrent review through discharge from the facility.
• Coordinate discharge planning and assist post-acute facility staff to ensure timely discharge.
• Employ effective use of critical thinking skills and knowledge of CMS clinical review criteria to ensure appropriate clinical decision-making.
• Ability to stay organized and interact well with others in any situation.
• Must be able to navigate software programs required to perform essential functions such as electronic medical record platforms.
• Possess strong interpersonal skills both in writing and telephonic to drive collaboration with post-acute facilities to ensure timely and accurate clinical updates are received throughout the members stay.
• Have strong personal accountability responsibility and independent decision-making abilities.

You should get in touch if:

• Hold a current and valid Compact Registered Nurse (RN) license (required).
• You have at least 2 years of experience in a post-acute or hospital setting (required).
• You have at least 1 year of experience performing medical necessity reviews using CMS criteria (required).
• You have strong knowledge of CMS guidelines and NCD/LCD policies.
• You have excellent interpersonal skills and ability to communicate with patients and colleagues.
• You have experience working remotely preferred.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally we offer a performance-based bonus program 401k matching and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical dental and vision coverage. Your health matters to us and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this we offer initiatives such as No-Meeting Fridays monthly company holidays access to mental health resources and a generous flexible time-off policy. Additionally we embrace a remote-first culture that supports collaboration and flexibility allowing our team members to thrive from any location.
• Professional Development: Developing internal talent is a priority for Clover. We offer learning programs mentorship professional development funding and regular performance feedback and reviews.

Additional Perks:

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture enabling collaboration with global teams
• Paid parental leave for all new parents
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken so weve created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise working together to solve the most complicated problem in the world: healthcare.

From Clovers inception Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths experiences perspectives opinions and backgrounds who share a passion for improving peoples lives. Diversity not only includes race and gender identity but also age disability status veteran status sexual orientation religion and many other parts of ones identity. All of our employees points of view are key to our success and inclusion is everyones responsibility.

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Pursuant to the San Francisco Fair Chance Ordinance we will consider for employment qualified applicants with arrest and conviction records.We are anE-Verify company.

A reasonable estimate of the base salary range for this role is $80000 to $100000. Final pay is based on several factors including but not limited to internal equity market data and the applicants education work experience certifications etc.

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