Utilization Management Clinical Reviewer

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 care
• Apply CMS guidelines, NCQA standards, and internal clinical policies when making authorization determinations
• Refer complex or non-compliant cases to Physician Advisors or Medical Directors as appropriate
• Collaborate with providers to support appropriate utilization of skilled nursing and therapy visits
• Serve as a clinical resource to internal team members and external partners, including providers, payers, and case managers
• Facilitate effective communication to ensure alignment on care plans, documentation standards, and authorization decisions
• Maintain accurate and timely documentation of reviews, decisions, and communications
• Identify trends or issues impacting quality or utilization and escalate to leadership or quality committees as needed

Office Location

Office located at 2415 E Camelback Road, Suite 700, Phoenix, AZ 85016

Remote Qualifications

• Education & Licensure: Graduate of an accredited nursing program (RN, LPN, or LVN), or Graduate of an accredited Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathology (SLP) program
• Active, 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 preferred
• Home health experience strongly preferred

Knowledge and Experience

• Strong understanding of home health regulations, CMS guidelines, and medical necessity criteria
• Knowledge of utilization management principles and care coordination practices
• Familiarity with NCQA and URAC standards preferred
• Ability to analyze clinical documentation and make independent, evidence-based decisions
• Excellent written and verbal communication skills
• Strong organizational skills with the ability to manage multiple priorities and meet deadlines
• Ability to work independently while collaborating effectively across teams
• Customer-service oriented mindset when working with providers and partners
• Proficiency in Microsoft Office and electronic medical management systems

Additional Expectations

• Participate in ongoing education and training
• Stay current on regulatory updates and clinical guidelines
• Contribute to a culture of quality, compliance, and continuous improvement