Hospice Utilization Review Nurse

JOL HEALTHCARE•Leander, TX

5d•$100,000 - $100,000

About The Position

The Utilization Review Nurse (RN) evaluates the medical necessity, appropriateness, and efficient use of hospice services through clinical chart review, utilization monitoring, and workflow oversight. The role ensures hospice care aligns with Medicare Hospice Conditions of Participation (42 CFR Part 418), Texas regulations, payer requirements, and agency policies. It emphasizes accurate and timely documentation in the Homecare Homebase (HCHB) EMR and close collaboration with interdisciplinary group (IDG) members to support high-quality, compliant hospice care. The nurse reviews admission records and ongoing clinical documentation for hospice eligibility, medical necessity, and continued appropriateness of services; monitors utilization and HCHB workflows; supports audits, surveys, and performance improvement; and provides feedback and education to clinical staff. The position participates in an assigned Administrator-on-Duty (AOD) on-call rotation, providing after-hours administrative and clinical support under the direction of the Hospice Administrator and Director of Nursing. This role does not serve as the licensed Hospice Administrator. The position is primarily office-based, with potential for remote or hybrid work based on agency policy and minimal travel for field support or in-person training. It involves frequent computer use and prolonged screen time, as well as working under some stressful conditions to meet deadlines and patient needs.

Requirements

Graduate of an accredited School of Nursing.
Current RN license in the state of Texas.
Current BLS certification.
Minimum of 2 years of clinical hospice experience.
Strong knowledge of Medicare hospice Conditions of Participation (42 CFR Part 418), hospice eligibility criteria, and interdisciplinary team processes.
Proficiency with electronic medical record systems and Microsoft Office applications.
Strong organizational, analytical, and communication skills.
Ability to manage multiple priorities while meeting regulatory and operational deadlines.
Working knowledge of Medicare and Medicaid hospice regulations.
Ability to manage stressful situations calmly and courteously.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Experience with Homecare Homebase (HCHB) strongly preferred.

Responsibilities

Review hospice admission documentation, clinical assessments, visit notes, plans of care, physician orders, certifications of terminal illness, and related records for eligibility, medical necessity, and regulatory compliance.
Ensure documentation supports terminal illness prognosis, hospice eligibility criteria, and continued appropriateness of services under Medicare hospice regulations.
Review IDG documentation to ensure plans of care reflect patient needs, goals, and hospice levels of care.
Collaborate with clinical staff to clarify, educate, and correct documentation discrepancies in a timely manner.
Evaluate visit utilization patterns, levels of care, and service frequency to promote efficient care and support compliance and reimbursement integrity.
Participate in the assigned AOD on-call rotation, providing after-hours administrative and clinical support under the direction of the Hospice Administrator and Director of Nursing.
Monitor and manage clinical workflows in HCHB to ensure timely completion of documentation, orders, and visit notes.
Track pending tasks, outstanding physician orders and certifications, and incomplete documentation using HCHB dashboards and reports.
Identify workflow delays and compliance risks, and communicate with appropriate team members to facilitate resolution.
Participate in internal audits and mock surveys to support readiness for CMS, Texas Health and Human Services, and accrediting organization reviews.
Assist with performance improvement initiatives related to hospice utilization, documentation accuracy, and quality outcomes.
Support compliance with federal and state hospice regulations, payer requirements, and agency policies and procedures.
Provide clinicians with ongoing feedback and education on hospice documentation standards, utilization expectations, and regulatory requirements.
Assist with onboarding and training new clinical staff on HCHB workflows, hospice documentation protocols, and utilization review processes.