Compact Registered Nurse, Home Health

Job Summary

To support the Utilization Management team, the remote Compact Registered Nurse, Home Health will review prior authorization requests for medical necessity, perform clinical reviews for Home Health services, and collaborate with healthcare providers to ensure compliance with CMS regulations.

Key responsibilities

• Review Home Health prior authorization requests and perform clinical reviews to ensure medically necessary care
• Collaborate with home health agencies and internal teams to obtain necessary clinical documentation for accurate determinations
• Maintain accurate documentation and manage multiple priorities while ensuring timely completion of utilization management reviews

Required qualifications

• Current and valid Compact Registered Nurse (RN) license
• At least 3 years of recent clinical nursing experience, including Home Health or Utilization Management
• Minimum of 1 year of experience performing medical necessity reviews using CMS criteria
• Strong knowledge of the Medicare Benefit Policy Manual and CMS regulations
• Experience navigating electronic medical records and utilization management systems