Utilization Review Nurse

tango - Phoenix, AZ

Job Title: Utilization Review Nurse

Position: Nurse Coordinator

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

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 according to 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 for all patients.
Assist provider staff and team members in identifying patient needs and coordinating care.
Monitor patient progress and outcomes while ensuring efficient and cost-effective utilization of health care 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.
Review documentation and provide feedback to clinicians regarding CMS Chapter 7 and Milliman Care Guidelines.
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 assessing and resolving utilization review problems.
Perform other duties as required or assigned.

Required Skills

Core Skills

Detail-oriented
Good organizational skills
Strong oral and written communication skills
Excellent time management skills
Self-directed
Flexible
Ability to work with minimal supervision

Preferred Skills

Utilization review/management experience
Case management experience
Working knowledge of home care regulatory and federal requirements
Knowledge of NCQA and URAC
Computer skills including MS Office products (Outlook, Excel, Word, Adobe)

Requirements

Experience: At least two years of general nursing experience in medical, surgical, or critical care, and 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:

COVID-19 Requirements: Not Specified

Benefits

Participation in appropriate continuing education as may be requested and/or required.
Personal responsibility for educational activities to enhance job-related skills and abilities.
Attendance at mandatory educational programs.