Utilization Review Nurse Job at IntePros, Phoenix, AZ

WW41K2FsZVY5Y1IweXZYMDZ5QjdMeXdma1E9PQ==
  • IntePros
  • Phoenix, AZ

Job Description

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

  • 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.

Job Tags

Remote work, Flexible hours, Weekend work,

Similar Jobs

Jamison Professional Services

Certified Electronic Reporter Job at Jamison Professional Services

Position: Certified Electronic Reporter (CER) Location: Birmingham, AL Jamison (Jamison) is currently seeking a qualified and motivated professional for the position of Certified Electronic Reporter. Court Reporter - Functions, Qualifications, and Skills...

Memorial Healthcare System

Medical Assistant - Neurology - FT - Days - $2,500 Sign on Bonus - MPG - Miami Midtown Job at Memorial Healthcare System

 ...tray/room set-up.Under the supervision of physician, physician assistant, nurse practitioner or nurse, assists with performing patient...  ...weight, takes brief history on current illness or injury, current medications, allergies, required screenings, and other pertinent... 

Darwill

Paid Media Specialist (Google Ads and Paid Social) Job at Darwill

 ...organization. Qualifications: ~ Bachelors degree in Marketing or similar field ~2-5 years of experience in media buying ~ Proven PPC/SEM experience ~ Proven paid social experience ~ Demonstrated ability to drive results and achieve key performance indicators (... 

Outlier AI

Video Producer (Remote) Job at Outlier AI

 ...and ability to assess technical aspects of model outputs. Nice to Haves: Experience in fields like literature, creative writing, history, philosophy, theology, etc. Prior writing or editorial experience (content strategist, technical writer, editor, etc.).... 

Innovations PSI

Temporary Administrative Assistant Job at Innovations PSI

Our client is searching for a highly organized Administrative Assistant to support their team with day-to-day operations. This role partners closely with the Wealth Management team to ensure excellent client service. This is a 6-12 month contract with the potential to ...