Utilization Review Nurse (Part Time remote)

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.

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.