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.
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 elevate quality‑of‑care concerns to the Quality Assurance Committee/QPUC.
Support the Utilization Review Committee/QPUC in addressing and resolving utilization‑related issues.
Qualifications
Graduate of an accredited program in professional, practical, or vocational nursing.
Current, active nursing license (RN, LPN, or LVN) in good standing with the Arizona Board of Nursing and other state boards as applicable.
Minimum of two (2) years of general nursing experience in medical, surgical, or critical care.
At least one (1) year of experience in utilization review/management, case management, or recent home health fieldwork.
Excellent oral and written communication abilities.
Proven time management skills and ability to meet deadlines.
Self‑directed, flexible, and able to work independently with minimal supervision.
Working knowledge of home care regulations and federal requirements.
Experience
Familiarity with home health and community‑based services.
Experience in utilization or case management preferred.
Knowledge of homecare, managed care, medical/nursing procedures, and community resources.
NCQA and URAC experience is a plus.
Proficiency with MS Office (Outlook, Word, Excel), Adobe, and multiple electronic medical record systems.
Seniority level
Mid‑Senior level
Employment type
Contract
Job function
Quality Assurance
Industries
Hospitals and Health Care
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