Utilization Review Nurse (Remote)

About Abby Care

Our mission is to redefine care for the most vulnerable. The healthcare system is failing the underserved. It's a struggle to find care, to afford care, and to receive quality care. We are a company currently in stealth mode that is transforming the healthcare experience for low-income families through purpose-built, thoughtful technology. We are led by a founder who grew up on Medicaid (public insurance) and personally knows the desperation of not being able to afford medically-necessary care. Here, we believe that anything can be achieved through pure will, determination, and grit. We value individuals with a similar mindset.

Overview:

The Home Health Utilization Review Specialist evaluates the medical necessity, appropriateness, and cost-efficiency of care provided to patients in a home health setting. This role ensures compliance with regulatory standards and payer guidelines, aiming to optimize patient outcomes. The UR Specialist reviews patient care plans, assesses ongoing services, and coordinates with insurance companies to facilitate proper care delivery.

Key Responsibilities:

Medical Necessity Review:

• Pre-Authorization: Review and approve home health care services prior to initiation, ensuring that treatment plans meet medical necessity criteria.
• Ongoing Service Review: Conduct concurrent reviews of ongoing home health services to ensure continued need for care.
• Retrospective Review: Analyze completed care plans and services post-discharge to ensure they complied with medical necessity and coverage guidelines.

Care Plan Assessment:

• Evaluate individual patient care plans created by home health providers, ensuring that they align with the patient's condition, goals of care, and payer guidelines.
• Review the frequency and duration of services, such as home health aide visits, ensuring they are necessary and appropriate for the patient’s needs.
• Recommend adjustments to care plans as necessary, such as reducing or extending services based on patient progress or lack of medical justification for ongoing care.

Patient Advocacy & Coordination:

• Advocate for the patient to receive the necessary care while ensuring services are in line with evidence-based practices.
• Work with home health care teams (nurses, therapists) to coordinate care that optimizes both patient outcomes and the efficient use of healthcare resources.
• Provide information and support to patients and their families on the home health services covered by their insurance plans, ensuring clear communication about care options.

Denial Management & Appeals:

• Handle denials of service by reviewing the reasons for denial and working with healthcare providers to either adjust the care plan or appeal the decision.
• Compile necessary clinical documentation for appeals and communicate with payer organizations to resolve issues and ensure the patient’s care is covered appropriately.

Qualifications:

Education:

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) with active license.
• Additional certifications such as Certified Case Manager (CCM), Certified Professional in Utilization Review (CPUR), or Accredited Case Manager (ACM) are preferred.

Experience:

• 2+ years of clinical experience in home health care, nursing, or related healthcare settings.
• Prior experience in utilization review, case management, or home health care management is highly desirable.

Familiarity with Medicare/Medicaid guidelines for home health, including coverage criteria.

Skills & Competencies:

• Clinical Knowledge: Strong understanding of home health care services, including (physical, occupational, and speech).
• Analytical Ability: Able to assess clinical data and medical records to determine the appropriateness of home health services based on patient diagnosis and condition.
• Regulatory Knowledge: Familiar with Medicare and Medicaid home health care policies, private insurance requirements, and medical necessity criteria.
• Communication Skills: Strong written and verbal communication skills to interact with healthcare providers, insurance representatives, and patients/families.
• Problem-Solving: Ability to resolve disputes or coverage issues, particularly when dealing with service denials or changes in patient care needs.
• Attention to Detail: Meticulous in reviewing medical records, care plans, and documentation to ensure compliance with payer requirements and prevent coverage.

Collaboration: Regular coordination with interdisciplinary teams, including nurses, therapists, social workers, and physicians, to ensure comprehensive care reviews.

Working Hours: 9AM to 5PM US EST