Responsible for providing effective clinical record reviews inclusive of medical necessity request/ denials, complaints, external medical records request, mortality and morbidity reviews. Monthly complaint log audits services. Participate in monthly clinical competency evaluations. Serves as a liaison to the clinical director and the director of performance improvement Possesses superior knowledge, skills and ability in clinical reviews services. Provides documents as requested by the COO and VP of Performance Improvement and Clinical Services.
Essential job duties:
1. Reports to the VP Performance Improvement and Clinical Services
2. Performs in-depth analysis and medical review of submitted medical records to determine medical necessity and Medicare/Medicaid Conditions of Participation
3. Participates in on site reviews/audits as necessary
4. Responsible for reviewing clinical complaints for Maryland and District of Columbia
5. Participates in 6-8 monthly chart reviews to support Bi monthly Kryterium reviews
6. Host the bi monthly Kryterium Review process, publishes a monthly schedule.
7. Participates in quality review of new admissions and development of the 485s is complete and updates are made timely.
8. Reviews weekly reports and provides feed back to the VP of Performance Improvement and Clinical Services, Performance Improvement
9. Provides clinical expertise and advisement in scheduling/billing analysis during visit verification.
10. Provides pertinent report for Quality Improvement processes.
11. Data collection and analysis required.
12. Provides determinations based on policies and procedures
13. Conducts research as necessary to provide clinical reviews and advisement
14. Host monthly meeting with staff in person or via teleconference
15. PC proficiency to include Word, Access, and Excel
Other job duties:
1. May perform other duties in addition to those outlined in this job description
Employee Excellence, All In, Action-oriented
• Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved
• Innovates through improvement of care and/or efficiency of operational processes.
• Dedicated to a standard of performance excellence and high quality.
• Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency
• Identifies, prioritizes and selects alternative solutions to determine best outcome
• Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands
• Anticipates problems and attempts to solve before they develop
-A minimum of 4 years of Home Care experience, 2 years in a health care setting management.
-Knowledge of the DC Department of Health, DHMH, CMS, CHAP, local fire marshal, OSHA, EPA and other appropriate agencies regulations, standards, guidelines and requirements.
-Licensed as a Registered Nurse in DC and Maryland
-BSN required Licensed as a Registered Nurse in DC and Maryland.