REPORTS TO: Manager, Utilization Management
POSITION DESCRIPTION:
The Utilization Review Nurse acts as a liaison in the coordination of resources and services to meet patients’ needs, promotes teamwork to optimize efficient and cost-effective use of health care resources, monitors the health care delivery plan to maximize positive patient outcomes, and maintains compliance with applicable laws and regulations and the policies of Professional Health Care Network. The clinician will monitor adherence to ensure the effective and efficient use of home care-based services and monitor the appropriateness of homecare admissions, resumptions of care, reauthorizations, and extended cert periods.
Primary duties include, but are not limited to:
ESSENTIAL FUNCTIONS:
- Processes patient prior and reauthorization requests as outlined by company policy.
- Makes determination of the need for continued home health care services by reviewing documentation submitted by providers in accordance with Medicare guidelines.
- Refers to the Utilization Review Physician Advisor cases that do not meet established guidelines for admission or continued care.
- Maintains accurate records of authorizations and communication with providers and payer plans pertaining to authorization for all patients.
- Assists provider staff and team members in identifying patient needs and coordinating care.
- Assists provider staff and team members in efficient and cost-effective utilization of health care resources and monitors patient progress and outcomes.
- Facilitates communication and provides ongoing customer service support to payer plan case managers, patients and provider staff and team members.
- Prepares and submits any required status or summary reports in a timely manner.
- Periodic weekend and holiday rotation and availability to address after hour health plan member needs related to home health management.
- Reviews documentation and provides feedback to clinicians regarding CMS Chapter 7 and Milliman Care Guidelines to ensure accurate assessment and review data, medical records reflect compliance with medical necessity, homebound status, visit utilization supported by individual patient assessment/ documentation support and transition (discharge) planning.
- Identifies problems related to the quality of patient care and refers them to the Quality Assurance Committee/QPUC.
- Assists the Utilization Review Committee/QPUC in the assessment and resolution of utilization review problems.
- Other duties as required and/or assigned.
OFFICE LOCATION:
Fully Remote
QUALIFICATIONS
- Is a graduate of an accredited school of professional nursing or an accredited practical or vocational nursing program.
- Has at least two years of general nursing experience in medical, surgical, or critical care, and at least one year of utilization review/management, case management or recent field experience in home health.
- Is currently licensed as a registered nurse, practical nurse, or vocational nurse in good standing through the Arizona Board of Nursing and other State Boards of Nursing as applicable.
- Is detail oriented and displays good organizational skills as well as good oral and written communication skills.
- Excellent time management skills with a proven ability to meet deadlines.
- Is self-directed, flexible, cooperative, and exhibits the ability to work with minimal supervision.
- Working knowledge of home care regulatory and federal requirements.
KNOWLEDGE AND EXPERIENCE:
Requires knowledge in the areas of home health community-based services; utilization/case management experience is preferred. Must have a working knowledge of homecare, managed care, medical/nursing staff procedures, and community resources. NCQA and URAC knowledge is helpful. Computer skills such as MS Office products - Outlook, Excel, Word, Adobe, and the ability to work within multiple electronic medical management systems.
CONTINUING EDUCATION REQUIREMENTS:
Company personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, company personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All company personnel must attend mandatory educational programs.
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.