Home Health Utilization Reviewer

Company:

Compassus

 

Position Summary

The Home Health Utilization Reviewer is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Health Utilization Reviewer ensures the presence of, and regulatory integrity of, documentation required to support the delivery of quality care for home health patients and their families. S/he plays a crucial role in ensuring the quality and appropriateness of patient care provided by the home health agency. S/he is responsible for reviewing and evaluating medical records, treatment plans, and patient progress to determine the necessity, effectiveness, and efficiency of home health services. S/he collaborates with interdisciplinary teams (IDT), healthcare providers, and insurance agencies to ensure compliance with established guidelines and regulations while optimizing patient outcomes.

Position Specific Responsibilities

• Conducts comprehensive reviews of patient medical records, and treatment plans, including management of simple and complex wounds, and care documentation to assess the appropriateness and necessity of home health services.
• Identifies any discrepancies or opportunities for improvement in patient care.
• Ensures adherence to home health regulations, guidelines, and standards set by relevant governing bodies, insurance companies, and accrediting agencies.
• Verifies that services provided meet the prescribed criteria for medical necessity and quality skilled home health care.
• Communicates and collaborates with healthcare professionals, including physicians, nurses, therapists, and other members of the care team, to gather necessary information for the utilization review process and ensure coordinated patient care.
• Participates in quality improvement initiatives, suggesting strategies to enhance patient outcomes and operational efficiency.
• Generates reports, and analyzes data and trends, to identify areas for improvement in the utilization review process.
• Maintains accurate and complete records of utilization review activities, decisions, and communications.
• Collaborates with billing and coding teams as requested to ensure proper documentation of services as requested to support accurate and timely reimbursement from insurance providers.
• Provides guidance and education to home health staff regarding utilization review processes, documentation requirements, and compliance standards to promote consistent and high-quality care delivery.
• Collaborates with Case Managers to support complex patient care needs, especially those requiring additional resources or authorizations.
• Provides education on strategies for effective care planning to drive positive outcomes.
• Joins in discussions to support the resolution of issues related to denied claims or medical necessity disputes.
• Stays up-to-date with changes in healthcare regulations, payer policies, and best practices in home health utilization review.
• Performs other duties as assigned.

Education and/or Experience

• Associates or Bachelor's degree in Nursing, or Bachelor's of Science degree in Physical Therapy, or Bachelor's of Science degree in Occupational Therapy required.
• Minimum of three (3) years of experience in healthcare required; preferably in a home health setting.
• Home health OASIS knowledge required.
• Knowledge and experience in visit utilization, managed care payor models, and quality improvement strongly preferred.

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, colleagues, investors, and external parties. Strong written and verbal communications.
• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.

Certifications, Licenses, and Registrations

• Active and unencumbered license as a Registered Nurse or a Physical Therapist, or an Occupational Therapist required.
• OASIS certification preferr