Utilization Review Nurse

Position Title : Utilization Review Nurse

Location : Fully Remote

Position Summary

The Utilization Review Nurse serves as a key liaison in coordinating resources and services to meet patients' needs, ensuring efficient, cost-effective, and compliant delivery of home health care. This role monitors admissions, reauthorizations, extended certification periods, and ongoing care to ensure adherence to Medicare and regulatory guidelines while promoting positive patient outcomes.

Essential Responsibilities

• Review and process prior authorizations and reauthorization requests in accordance with company policy.
• Assess medical documentation to determine the need for continued home health services based on Medicare guidelines.
• Refer cases outside of established guidelines to the Utilization Review Physician Advisor.
• Maintain accurate and timely records of authorizations, communications, and payer interactions.
• Collaborate with provider staff to identify patient needs, coordinate care, and ensure appropriate resource utilization.
• Monitor patient progress and outcomes to support efficient, cost-effective care.
• Serve as a communication link and provide customer service support to payer case managers, patients, and provider teams.
• Submit required status and summary reports within deadlines.
• Participate in weekend and holiday rotation; remain available for after-hours support as needed.
• Review clinical documentation for compliance with CMS Chapter 7 and Milliman Care Guidelines; provide feedback to clinicians on medical necessity, homebound status, visit utilization, and discharge planning.
• Identify and escalate quality-of-care concerns to the Quality Assurance Committee / QPUC.
• Support the Utilization Review Committee / QPUC in addressing and resolving utilization-related issues.

Qualifications

Knowledge & Skills