Utilization Review Nurse

Personal Touch Home Health Care Services Inc.; Baldwin Park (CA); On-site; USD 70,000 - 110,000; Full time

Job summary

Personal Touch Home Health Care Services Inc. in Baldwin Park, CA is seeking a clinical reviewer to evaluate medical records and treatment plans for medical necessity and efficient utilization. The role ensures care aligns with established standards and promotes cost-effective decisions.

You will collaborate with physicians, caregivers, and care teams to coordinate coverage, support discharge planning, and promote compliant, high-quality health care delivery.

Qualifications

• Strong clinical judgment and ability to interpret medical records and treatment plans.

Responsibilities

• Assess clinical documentation to support coverage decisions and ensure care aligns with established standards.
• Evaluate requested services for medical necessity, appropriateness, and cost-effective utilization.
• Collaborate with physicians, members, caregivers, and care teams to coordinate care and coverage.
• Support discharge planning and identify cost-of-care options that promote compliant, effective care.
• Coordinate referrals as needed to ensure continuity of care.
• Maintain a focus on compliant decision-making and efficient health care delivery.

Skills

Clinical judgment

Medical necessity knowledge

Collaboration & communication

Cost-conscious decision making

Job description

Role Summary

Reviews medical records and treatment plans to determine medical necessity, appropriateness, and efficiency of requested health care services.

Key Responsibilities

• Assess clinical documentation to support coverage decisions and ensure care aligns with established standards.
• Evaluate requested services for medical necessity, appropriateness, and cost-effective utilization.
• Collaborate with physicians, members, caregivers, and care teams to coordinate care and coverage.
• Support discharge planning and identify cost-of-care options that promote compliant, effective care.
• Coordinate referrals as needed to ensure continuity of care.
• Maintain a focus on compliant decision-making and efficient health care delivery.

Qualifications & Skills

• Strong clinical judgment and ability to interpret medical records and treatment plans.
• Knowledge of medical necessity and utilization review principles.
• Excellent collaboration and communication skills with multidisciplinary care teams.
• Ability to make sound, cost-conscious decisions that support quality and compliance.