About This Role
Evaluating the medical necessity, appropriateness, and efficient use of hospice services is the core of this role, ensuring that care delivery aligns with regulations and agency policy. The Utilization Review Nurse focuses on accurate, timely, and compliant documentation within the Homecare Homebase (HCHB) EMR system and collaborates with the interdisciplinary team to support high-quality hospice care.
Responsibilities
- Conduct a comprehensive review of hospice admission documentation, ongoing clinical assessments, visit notes, plans of care (POCs), physician orders, certifications of terminal illness (CTIs), and related records to confirm hospice eligibility, medical necessity, and regulatory compliance
- Ensure documentation supports terminal illness prognosis, hospice eligibility criteria, and continued appropriateness of services in accordance with Medicare hospice regulations
- Review interdisciplinary group (IDG) documentation to ensure plans of care reflect patient needs, goals, and hospice levels of care
- Collaborate with clinical staff to clarify, educate, and correct documentation discrepancies on time
- Evaluate visit utilization patterns, levels of care, and service frequency to promote efficient care delivery while supporting compliance and reimbursement integrity
- Participate in the assigned Administrator-on-Duty (AOD) on-call rotation, providing administrative and clinical support after hours under the direction of the Hospice Administrator and Director of Nursing
- Monitor and manage clinical workflow within the HCHB system to ensure timely completion of documentation, orders, and visit notes
- Track pending tasks, outstanding physician orders, certifications, and incomplete documentation using HCHB dashboards and reports
- Identify workflow delays or compliance risks and proactively communicate with appropriate team members to facilitate resolution
- Participate in internal audits and mock surveys to support readiness for CMS, Texas Health and Human Services, and accrediting organization reviews
- Assist with performance improvement initiatives related to hospice utilization, documentation accuracy, and quality outcomes
- Support compliance with federal and state hospice regulations, payer requirements, and agency policies and procedures
- Provide ongoing feedback and education to clinicians related to hospice documentation standards, utilization expectations, and regulatory requirements
- Assist with onboarding and training of new clinical staff related to HCHB workflows, hospice documentation protocols, and utilization review processes
Requirements
- Graduate of an accredited School of Nursing; BSN preferred
- Current RN license in the state of Texas
- Current BLS certification
