Hospice Utilization Review Nurse

The Utilization Review Nurse (RN) is responsible for evaluating the medical necessity, appropriateness, and efficient use of hospice services through detailed clinical chart review, utilization monitoring, and workflow oversight. This role ensures that hospice care delivery aligns with Medicare Hospice Conditions of Participation (42 CFR Part 418), Texas regulations, and agency policy. The Utilization Review Nurse places strong emphasis on accurate, timely, and compliant documentation within the Homecare Homebase (HCHB) EMR system and collaborates closely with interdisciplinary team (IDG) members to support high-quality, compliant hospice care.

Essential Functions:

Utilization Review & Clinical Oversight:

• 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. This role does not serve as the licensed Hospice Administrator.

HCHB Workflow Monitoring:

• 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.

Quality & Compliance Support:

• 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.

Staff Support & Education:

• 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.

Education:

Graduate of an accredited School of Nursing; BSN preferred.

License/Certification:

• Current RN license in the state of Texas.

• Current BLS certification.

Experience:

• Minimum 2 years of clinical hospice experience.

• Strong knowledge of Medicare hospice Conditions of Participation (42 CFR Part 418), hospice eligibility criteria, and interdisciplinary team processes.

• Experience with Homecare Homebase (HCHB) is strongly preferred.

Skills:

• Proficient with electronic medical record systems and Microsoft Office applications. 
  Strong organizational, analytical, and communication skills.

• Ability to manage multiple priorities while meeting regulatory and operational deadlines.

• Working knowledge of Medicare and Medicaid hospice regulations.

Environmental and Working Conditions:

• Primarily office-based with potential for remote/hybrid work (based on agency policy).

• May require minimal travel for field support or in-person training.

• Frequent use of computer systems and prolonged screen time.

Physical and Mental Effort:

• Prolonged sitting and computer use are required.

• Ability to manage stressful situations calmly and courteously.

• Requires working under some stressful conditions to meet deadlines and patient needs.