Home Health Registered Nurse

About the role

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. As an integral part of the multidisciplinary care team, the Nurse conducts reviews to assess utilization, quality, and tenure of services for identified home health patients.

Responsibilities

• Works with providers and 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.
• Reviews all home health agency communications and provides documentation as needed.
• Assists with DME requests.
• Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.
• Refers cases that do not meet medical necessity, benefit eligibility, and network contract status criteria for provider review, ensuring timely review.
• Provides timely and frequent communications with the PCP and practice team to maximize patient needs management 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 healthcare services in compliance with Health Center, ACO, and regulatory standards.
• Participates 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 opportunities to improve, test, and document outcomes of care processes, including safety and satisfaction.
• Participates in QI initiatives that support Home Health Utilization and ensures care is patient-centered and culturally sensitive.

Supervisory Responsibility

May provide guidance to LPNs, medical assistants, or non-clinical Call Center staff by directing protocols to facilitate patient care.

Qualifications

• Bachelor’s degree in nursing required; Master’s degree in nursing or Public Health preferred.
• Licensed as a RN by the Massachusetts State Board of Registration.
• BLS certification required.
• Home health experience and a clear understanding of home health service lines available to patients required.
• Ideal candidate has home health discharge planning and utilization review experience, preferably with a health insurance company.

Reporting Relationship: Director of Population Health