Clinical Reviewer

The 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 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 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
Monitor adherence to home health regulations, documentation standards, and medical necessity criteria
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 7
Participate in interdisciplinary collaboration and support continuous improvement initiatives
Meet productivity, turnaround time, and quality standards for review completion 8
Participate in periodic weekend/holiday coverage based on business needs 9 10
Perform additional duties as assigned

Office Location:

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

Qualifications:

Education & Licensure (one of the following required):

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

Employees are expected to:

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