Position Summary:
The Home Health Utilization Nurse is a member of the Primary Care Team and coordinates home health, quality improvement, and utilization review improvements for health center patients. The Nurse, as an integral part of the multidisciplinary care team, is responsible for conducting reviews in order to assess utilization, quality and tenure of services for identified home health patients.
Program Specific Essential Duties and Responsibilities:
- Works with provider's/support staff to facilitate cost effective, quality care.
- Communicates determinations to providers and home care agencies in writing, adhering to Health Center, ACO and payer policies and guidelines.
- Review all home health agency communications and provide documentation as needed.
- Assist with DME requests
- Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.
- Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria for Provider review for consideration, ensuring the timely review of the referred case.
- Provides timely and frequent communications with the PCP and practice team to maximize the management of patient needs and related risk reduction.
- Acts as a liaison between assigned agencies, members/families, and the Health Center.
- Authorizes services, coordinates care, and ensures timeliness and coordination of health care services, in compliance with the health center, ACO and regulatory standards, seeking supplemental services when appropriate or when needed.
- Participate in monthly meetings with home health agencies and ACO
Program Specific Essential Duties and Responsibilities:
- Works with provider's/support staff to facilitate cost effective, quality care.
- Communicates determinations to providers and home care agencies in writing, adhering to Health Center, ACO and payer policies and guidelines.
- Review all home health agency communications and provide documentation as needed.
- Assist with DME requests
- Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.
- Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria for Provider review for consideration, ensuring the timely review of the referred case.
- Provides timely and frequent communications with the PCP and practice team to maximize the management of patient needs and related risk reduction.
- Acts as a liaison between assigned agencies, members/families, and the Health Center.
- Authorizes services, coordinates care, and ensures timeliness and coordination of health care services, in compliance with the health center, ACO and regulatory standards, seeking supplemental services when appropriate or when needed.
- Participate in monthly meetings with home health agencies and ACO
- Refers high risk cases to the Care Management department, and/or other community services according to treatment protocol.
- Integrates quality improvement strategies to identify an opportunity to improve, test, and document an outcome of a care process to improve the quality of care. Includes safety and satisfaction as an outcome.
- Participates in QI initiatives that support Home Health Utilization. Assures that care is patient-centered and culturally sensitive
Supervisory Responsibility:
May be asked to provide guidance to LPNs, medical assistants or non-clinical Call Center staff by providing direction with protocols to facilitate patient care.
Qualifications and Education Requirements:
One of the following combinations of education and employment experience must be met in order to be considered for the position:
Education And Experience:
- Bachelor's degree in nursing required. Master's degree in nursing or Public Health preferred.
- Must be licensed as a RN by the Massachusetts State Board of Registration. BLS required.
- Home health experience and a clear understanding of the various home health line service lines available to patients is required.
- The ideal candidate would have home health discharge planning and utilization review experience (preferably with a health insurance company).
Reporting Relationship: Director of Population Health
EOE
Monday-Friday; 8:30am -5:00pm