Manager Utilization Management Jobs in Manchester, NH

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking RN, Home Health Program Nurse Coordinator to join our team. The Home Health Program Nurse Coordinator (RN) works under the supervision of the Director of Population Health and serves as the central coordinator for all home health referrals within the organization. This role manages and monitors provider-initiated referrals to home health agencies to ensure timely initiation, appropriateness of services, and continuity of care. The Home Health Program Nurse coordinator acts as the primary liaison between medical providers, care teams, patients, and home health agencies and is critical in holding home health agencies accountable for delivering patient-centered, high-quality care aligned with clinical expectations and care plans. Works in collaboration with discharging facilities, and care management teams to facilitate appropriate referrals for GLFHC patients.

This role oversees referral processing, monitors the progress of home health services, and supports the certification and recertification process to ensure services remain medically necessary and aligned with the patient's care plan. This position plays an important role in supporting value-based care, by promoting appropriate use of home health services, improving care coordination, and helping patients safely receive effective care in the home setting, helping to improve health outcomes while reducing unnecessary utilization and expenses. This role does not provide direct care; it manages and oversees the Home Health Program in a care coordination role and does not include direct home health nursing visits or field-based clinical care.

Utilization Management

• The RN will serve as a central access point for all referrals to home health providers, including evaluating medical necessities and appropriate utilization based on clinical acuity.
• Remains current in interpreting reimbursement guidelines to ensure patients' services meet coverage criteria.
• Review provider-initiated referral to ensure completeness, clinical appropriateness, including medical necessity that aligns with payor requirements.
• Serves as a subject matter expert for the integrated care team, including working with nursing to facilitate home health referrals.
• Coordinate with providers and care teams to obtain necessary documentation required for home health services.
• Maintain an organized tracking system for all active referrals and home health services.

Agency Coordination and Oversight

• Serve as the primary point of contact for home health agencies, facilitating communication between agencies, providers, and care teams.
• Monitors the initialing and progress of home health services to ensure timely start of cases and adherence to the prescribed care plan.
• Follow up with agencies regarding delays in care initiation, missed visits, or deviations from expected service plans.
• Escalate concerns regarding patient safety, services delays, or agency performance to appropriate providers or leadership.
• In collaboration with home health providers, develops relationships and conducts ongoing assessments of their clinical capability based on population served.

Certification and Recertification Oversight

• Track all active home health referrals and services, maintaining an accurate registry to monitor patient progress and engagement.
• Follow up providers and home health agencies to completion of required documentation, orders and care plans.
• Review agency updates and documentation to determine whether services continue to meet medical necessity requirements.

Care Coordination and Patient Support

• Collaborate with integrated care team including case managers, providers and Behavioral health staff, to ensure seamless coordination across all patient transitions
• Participate in interdisciplinary care team meetings to provide input on patients receiving home health services.
• Educate patients and caregivers on the purpose of home health services and ensure they understand care plan.

Quality Improvement and Population Health

• Identify gaps in care and escalate concerns regarding patient safety, service delays, or non-compliance
• Provide input on referral processes and performance of home health agencies for quality improvement purposes
• Participate in ACO Home Health meetings to share updates, identify systemic challenges, and support population health strategies.
• Ensure compliance with HIPAA and all applicable federal, state and local regulations related to patient care and documentation.

Qualifications

• Minimum of seven years of clinical nursing experience, including a minimum of three years of experience working within a home health practice.
• Additional experience in utilization management, highly desirable.
• Proven ability to develop and maintain strong professional relationships with the Home Health community.
• Strong clinical assessment skills and understanding of home health eligibility criteria.
• Excellent organizational and communication skills.
• Experience working in community health center or primary care setting.
• Familiarity with local home health agencies and referrals workflow.
• Proficient in EHR systems and Microsoft Office.
• A valid driver's license and access to reliable transportation. A vehicle is necessary to drive to and from each site as needed.

Education

• Bachelor's degree in Nursing with Massachusetts RN Licensure.

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.

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