Utilization Review Nurse

tango - Phoenix, AZ

Job Title: Utilization Review Nurse

Position: Nurse in Utilization Management

Job Type: Full Time

Pay:

Shift: Periodic weekend and holiday rotation; availability after hours

Work Type: Remote

Location

Address:

City: Phoenix

State: AZ

ZIP Code:

Job Responsibilities

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 cases that do not meet established guidelines for admission or continued care to the Utilization Review Physician Advisor.
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.
Monitors patient progress and outcomes while ensuring efficient and cost-effective utilization of health care resources.
Facilitates communication and provides ongoing customer service support to payer plan case managers, patients, and provider staff.
Prepares and submits any required status or summary reports in a timely manner.
Reviews documentation and provides feedback to clinicians regarding CMS Chapter 7 and Milliman Care Guidelines.
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.
Performs other duties as required and/or assigned.

Required Skills

Core Skills

Detail oriented
Good organizational skills
Excellent oral and written communication skills
Excellent time management skills
Self-directed
Flexible
Ability to work with minimal supervision
Working knowledge of home care regulatory and federal requirements

Preferred Skills

Utilization/case management experience
Knowledge of NCQA and URAC
Computer skills such as MS Office products (Outlook, Excel, Word, Adobe)
Ability to work within multiple electronic medical management systems

Requirements

Experience: 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.

Education: Graduate of an accredited school of professional nursing or an accredited practical or vocational nursing program.

License & Certification:

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.

Schedule:

Periodic weekend and holiday rotation
Availability after hours

COVID-19 Requirements: Not Specified

Benefits

Not specified

Supplemental Pay

Not specified

Special Notes

Company personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor.
All company personnel must attend mandatory educational programs.