Home Health Coding and Quality Review - Yale New Haven Health

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The QA Home Care Reviewer will facilitate the process of improving clinical documentation through extensive clinical documentation reviews and concurrent interactions with clinicians to fully capture a patients condition, complicationsband co-morbidities. The QA Home Care Reviewer will educate nurses, clinicians, and staff on documentationbimprovement opportunities, OASIS compliance, reimbursement and relevant quality and performance improvement opportunities. The QA Home Care Reviewer will identify documentation issues related quality of care and will seek resolution through the appropriate channels. Responsible for review of all clinical records regarding the OASIS and other clinical documentation and ensuring compliane with applicable State and Federal laws and regulations, Medicare guidance, and other policies and procedures.

EEO/AA/Disability/Veteran

1. Performs comprehensive clinical record reviews of start of care, resumptions of care, re-certifications, and discharge for complete and accurate clinical documentation to ensure the OASIS and /or assessment accurately reflects the patients current health status

1.1 Completes reviews within designated time frames.

1.2 Reviews documentation for necessity of services, congruency, accuracy, appropriateness, quality of care and compliance with physician orders and the plan of care to ensure quality care and reimbursement.

1.3 Collaborates with coding staff concurrently and retrospectively to ensure the OASIS and the medical chart are accurate

1.4 Perform final review and lock OASIS

2. Educates on OASIS requirements, clinical documentation, clinician educational training and support, and State and Federal regulatory requirements. Develops and conducts ongoing education including new team members, clinicians, and other staff.

2.1 Provides in person or virtual training to providers 1:1, or in small groups

3. Develops and supports strong collaborative professional relationships with peers, coding staff, clinical team members and medical providers.

4. Utilizes a compliant query process when conducting all clinical queries. Follows each query through to closure including complete documentation on ongoing follow up activities and communication.

5. Maintains proficiency in OASIS data and data capture best practices according to industry guidelines and CMS instructions.

6. Prepares periodic reports/dashboards, as requested, that aid in various initiatives often with a direct impact to star ratings/quality reporting.

7. Works collaboratively with clinical and administrative leadership to ensure positive and compliant program outcomes

8. Provides ongoing OASIS team learning opportunities through sharing of professional knowledge

9. Maintains integrity and compliance in all chart reviews, documentation and queries at all times

10. Supports and implements quality measures as identified by department manager 

11. Identifies opportunities for performance improvement.

12. Assures home care compliance with OASIS requirements and remains current with regulatory and organization requirements to ensure accurate and thorough quality assurance reviews. Subject matter experts regarding CMS guidelines and OASIS review.

13. Performs utilization review of existing clinical documents for potential under and over utilization of services

14. Active participation in staff meetings, and other meetings as requested.

15. Adheres to the practice of confidentiality regarding patients, staff and the organization

16. Assists in other monitoring, training, special department projects or initiatives or other needs as determined by the department leadership.

EDUCATION: Registered Nurse with active license, BSN preferred. HCS-D coding certification preferred. LPN with an active license accepted with a minimum of three years experience required in Quality Assurance in Home Health and Hospice

EXPERIENCE: At least three (3) years of recent clinical nursing experience required. Home Health and Hospice preferred. Clinical expertise required. At least one (1) year of OASIS QA review experience required. Experience conducting quality assurance and continuous improvement activities.

SPECIAL SKILLS: Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters throughout the health system and community. Comprehensive understanding in use of medical record to
extract data. Working knowledge of third party and prospective payment systems relating to home care and hospice. Thorough knowledge of home care quality assurance process. Computer PC literacy required. Must be able to work collaboratively and independently. Must have keen eye to detail. Must be adaptable, flexible, have ability to learn quickly, use critical thinking, and be able to motivate staff. Strong computer skills.

ACCOUNTABILITY: Communicates effectively, adheres to Standards of Professional Behavior and High Reliability Organizations. Knowledge and ability to audit OASIS and SN/PT/OT/ST/MSW/HHA and hospice visit notes.

COMPLEXITY: In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic). Requires a considerable understanding of the Quality Assurance process for home care, OASIS, Face to -Face, home care regulations and Conditions of Participation. Exercises independent judgment and tact in dealing with physicians, clinicians, and others. Serves as a resource on home care quality assurance processes. Participates in the orientation of new staff.

LICENSURE/CERTIFICATION: RN license required. LPN with an active license accepted with a minimum of three years experience in Quality Assurance in Home Health and Hospice in lieu of RN license. HCS-D Home Care Coding Certification a plus. COQS (Certified OASIS Quality Specialist) or HCS-O (Certified Home Care Clinical Specialist) required within 12 months of hire.

Must be capable of standing, walking, and bending. Ability to communicate clearly and confidently to providers the program goals and documentation issues using email, in person communication, telephone and other written and electronic forms of communication.