Job Description

Job Title: Clinical UM Reviewer - Home Health
Job ID: 64139936
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Home Healthcare
Department: Utilization Review North
Location: 300 Northepoint Circle, Seven Fields PA 16046


The Utilization Management Reviewer position will provide and review specific data points in Home health and help the assessing clinician meet the Conditions of Participation, quality, coding, payer and OASIS regulations.  

  • Maintain and protect patient and agency confidentiality
  • Promote personal and co-worker safety during work duties
  • Educate and require adherence to performance improvement processes and initiatives
  • Conduct a comprehensive review and analysis of the patient's Plan of Treatment, (POT) to: Ensure eligibility criteria for home health services and compliance with accrediting and licensing bodies
  • Ensure accurate ranking and coding of patient's medical diagnosis related to the patient's condition
  • Validate patient condition is accurately reflected in Outcome Assessment Information Set, (OASIS) scores
  • Incorporate program Best Practices into the care planning process
  • Validate that resource utilization/services are consistent with assessment/OASIS findings
  • Validate patient goals are appropriate, meaningful, and achievable
  • Function as an expert resource and provide new hires ongoing continuing education to supervisors and field staff related to OASIS best practice and POT Accuracy
  • Process Plans of Treatment for signature
  • Demonstrate knowledge of payment and reimbursement structures
  • Expand knowledge and expertise through educational resources and literature review
  • Demonstrate support of the UPMC Mission, Principles, and Values, Ethics & Standards of Behavior
  • Communicate review findings, inconsistencies in OASIS data, medical diagnoses, and documentation to clinical staff and /or supervisor
  • Obtain additional information to resolve clinical and coding inconsistencies
  • Compile and trend deficits to identify areas for improvement and agency educational needs
  • Ensure the OASIS answers are consistent with the patient's POT
  • Meet established productive standards
  • Utilize decision support systems data and reports to establish POTs, visit utilizations patterns/frequency, and identify inconsistencies with assessment data


Must meet one of the following criteria: 
  • Graduate of an accredited nursing program
  • Licensed as Registered Nurse by the Pennsylvania State Board of Nursing
  • Graduate of a physical therapy education program approved by the Commission on Accreditation in Physical Therapy Education (CAPTE or APTA)
  • Licensed through examination by the Pennsylvania State Board of Physical Therapy
  • Graduate of an Occupational Therapy Program, which meets the requirements of the Accreditation Council for Occupation Therapy Education, (ACOTE) of the AOTA and be licensed through examination by the state Board of Occupational Therapy
  • Graduate at a Master's level which meets education requirements for a Certificate of Clinical Compliance (CCC) in Speech Pathology or Audiology or meets the education requirements for certification and is in the process of accumulating the supervised experiences required by Certification
Other Requirements/Preferences:
  • Computer Skills, competency in computer skills and point of care software
  • 2 years in home health experience is required
  • 2 years utilization review experience is preferred
  • Demonstrate proficiency in Medicare, Medicaid and commercial insurance regulations
  • Knowledge of ICD 10 coding is required
  • Current employees would be supported to obtain certification
  • Travel- Access to transportation in the agency service area with valid driver's license and auto liability insurance

Licensure, Certifications, and Clearances:
  • Occupational therapist OR Registered Nurse (BSN preferred) OR Speech Language Pathologist OR Physical Therapist
  • OASIS Certification required within 18 months. If certification is not attained, measurement of performance through inter-rater reliability (IRR) will be required annually
  • ICD 10 Coding Certification required within 18 months of hire (grandfathered if hired before 2019)
  • Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)
  • Act 34
UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $24.08 to $41.23 / hour

Union Position: No

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