Utilization Management Clinical Reviewer

Brief Description The Utilization Management (UM) Clinical Reviewer is responsible for performing utilization review activities to ensure the appropriate, efficient, and cost-effective use of home health services. This role evaluates medical necessity for skilled nursing and therapy services (physical therapy, occupational therapy, and speech-language pathology) in accordance with company policies, CMS guidelines (including Medicare Chapter 7), and established clinical criteria such as Milliman Care Guidelines. The UM Clinical Reviewer collaborates with providers, internal teams, and payer partners to promote high-quality patient outcomes, ensure regulatory compliance, and support optimal care planning across disciplines. Key Responsibilities Review and process prior authorization, reauthorization, and continued stay requests for home health services (nursing and therapy)Evaluate medical records and clinical documentation to determine medical necessity and appropriateness of careApply CMS guidelines, NCQA standards, and internal clinical policies when making authorization determinationsRefer complex or non-compliant cases to Physician Advisors or Medical Directors as appropriateCollaborate with providers to support appropriate utilization of skilled nursing and therapy visitsServe as a clinical resource to internal team members and external partners, including providers, payers, and case managersFacilitate effective communication to ensure alignment on care plans, documentation standards, and authorization decisionsMonitor adherence to home health regulations, documentation standards, and medical necessity criteriaMaintain accurate and timely documentation of reviews, decisions, and communicationsIdentify trends or issues impacting quality or utilization and escalate to leadership or quality committees as needed 7Participate in interdisciplinary collaboration and support continuous improvement initiativesMeet productivity, turnaround time, and quality standards for review completion 8Participate in periodic weekend/holiday coverage based on business needs 9 10Perform additional duties as assigned Office Location: Office located at 2415 E Camelback Road, Suite 700, Phoenix, AZ 85016Remote Qualifications Education & Licensure (one of the following required): Graduate of an accredited nursing program (RN, LPN, or LVN), orGraduate of an accredited Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathology (SLP) programActive, unrestricted clinical license in good standing (multi-state licensure preferred where applicable) Experience Minimum 2–5 years of clinical experience (home health, medical/surgical, or therapy setting)Experience in utilization review, case management, or managed care strongly preferredHome health experience strongly preferred Knowledge And Experience Strong understanding of home health regulations, CMS guidelines, and medical necessity criteriaKnowledge of utilization management principles and care coordination practicesFamiliarity with NCQA and URAC standards preferredAbility to analyze clinical documentation and make independent, evidence-based decisionsExcellent written and verbal communication skillsStrong organizational skills with the ability to manage multiple priorities and meet deadlinesAbility to work independently while collaborating effectively across teamsCustomer-service oriented mindset when working with providers and partnersProficiency in Microsoft Office and electronic medical management systems Additional Expectations Employees are expected to: Participate in ongoing education and trainingStay current on regulatory updates and clinical guidelinesContribute to a culture of quality, compliance, and continuous improvement tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.