[Hiring] Utilization Management Clinical Reviewer @Professional Health Care Network

Role Description

We are currently looking for a Utilization Management (UM) Clinical Reviewer to join our growing team for a TUESDAY - SATURDAY shift. 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.

• 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
• Participate in interdisciplinary collaboration and support continuous improvement initiatives
• Meet productivity, turnaround time, and quality standards for review completion
• Participate in periodic weekend/holiday coverage based on business needs
• Perform additional duties as assigned

Qualifications

• 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)

Requirements

• 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
• 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

Company Description

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.