Utilization Review Nurse

Tango • Phoenix, AZ

443d • Remote

About The Position

The Utilization Review Nurse serves as a critical liaison in coordinating resources and services to meet patient needs, ensuring efficient and cost-effective use of healthcare resources. This role involves monitoring healthcare delivery plans to maximize positive patient outcomes while maintaining compliance with relevant laws and regulations. The nurse will oversee home care services, including admissions, reauthorizations, and extended certification periods, while providing support to healthcare teams and patients.

Requirements

• Graduate of an accredited school of professional nursing or an accredited practical or vocational nursing program.
• At least two years of general nursing experience in medical, surgical, or critical care.
• At least one year of utilization review/management, case management, or recent field experience in home health.
• 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.
• Detail-oriented with good organizational skills and strong oral and written communication skills.
• Excellent time management skills with a proven ability to meet deadlines.
• Self-directed, flexible, cooperative, and able to work with minimal supervision.
• Working knowledge of home care regulatory and federal requirements.

Nice To Haves

• Knowledge in home health community-based services; utilization/case management experience is preferred.
• Working knowledge of homecare, managed care, medical/nursing staff procedures, and community resources.
• Familiarity with NCQA and URAC standards.
• Computer skills in MS Office products - Outlook, Excel, Word, Adobe, and ability to work within multiple electronic medical management systems.

Responsibilities

• Process patient prior and reauthorization requests as outlined by company policy.
• Determine the need for continued home health care services by reviewing documentation submitted by providers in accordance with Medicare guidelines.
• Refer cases that do not meet established guidelines for admission or continued care to the Utilization Review Physician Advisor.
• Maintain accurate records of authorizations and communication with providers and payer plans pertaining to authorization for all patients.
• Assist provider staff and team members in identifying patient needs and coordinating care.
• Monitor patient progress and outcomes to ensure efficient and cost-effective utilization of healthcare resources.
• Facilitate communication and provide ongoing customer service support to payer plan case managers, patients, and provider staff.
• Prepare and submit required status or summary reports in a timely manner.
• Participate in periodic weekend and holiday rotation and be available to address after-hour health plan member needs related to home health management.
• Review documentation and provide feedback to clinicians regarding compliance with medical necessity and homebound status.
• Identify problems related to the quality of patient care and refer them to the Quality Assurance Committee/QPUC.
• Assist the Utilization Review Committee/QPUC in the assessment and resolution of utilization review problems.

Benefits

• Equal employment opportunities without discrimination or harassment.
• Reasonable accommodations for qualified individuals with known disabilities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Professional, Scientific, and Technical Services
• Education Level: No Education Listed