Utilization Review Nurse

Job Summary:

The Utilization Review Nurse (RN) is responsible for evaluating the medical necessity, appropriateness, and efficiency of home health services through detailed clinical chart review and workflow oversight. This role ensures that care delivery aligns with Medicare regulations, clinical standards, and agency policy. A strong focus is placed on documentation accuracy within the Homecare Homebase (HCHB) EMR system. The UR Nurse collaborates closely with clinical teams to ensure timely, compliant, and high-quality care.

Key Responsibilities:

Utilization Review & Clinical Oversight:

• Conduct a comprehensive review of OASIS assessments, visit notes, plans of care, and orders to confirm medical necessity and compliance.
• Ensure that documentation supports homebound status and skilled need per CMS guidelines.
• Collaborate with field clinicians to clarify and correct documentation discrepancies.
• Evaluate visit utilization patterns to optimize care delivery while ensuring reimbursement compliance.

HCHB Workflow Monitoring:

• Monitor and manage clinical workflow within the HCHB system, ensuring timely completion of documentation and visit notes.
• Track pending tasks, outstanding orders, and overdue items via HCHB dashboards.
• Support care coordination by identifying delays or issues in workflow and addressing them proactively.

Quality & Compliance Support:

• Participate in internal audits to ensure regulatory readiness (CMS, Joint Commission, etc.).
• Assist with performance improvement initiatives related to documentation, utilization, and care quality.
• Support compliance with agency policies, payer requirements, and federal/state home health regulations.

Staff Support & Education:

• Provide feedback to clinicians to improve documentation practices and understanding of utilization standards.
• Assist with training new staff in HCHB use, documentation protocols, and UR processes.

Qualifications:

• Education: Graduate of an accredited School of Nursing; BSN preferred.
• License/Certification: Current RN license in [State]; BLS certification.
• Experience:
  • Minimum 2 years of clinical home health experience.
  • Strong knowledge of OASIS, CMS regulations, and Medicare Conditions of Participation.
  • Experience with Homecare Homebase (HCHB) strongly preferred.
• Skills: Excellent critical thinking, attention to detail, and communication skills. Proficient in EMR systems and workflow monitoring.