Role and Responsibilities
The Utilization Review Specialist is responsible for performing utilization review activities including technical audit of assigned patient electronic medical records. This position is critical to the organization's Quality Assurance and Compliance programs to ensure HCR is providing safe and quality care by adhering to federal, state, and payer regulations. This position works in collaboration with the authoring clinicians of reviewed records. Requires collaboration with staff development and clinical management to report identified trends.
This is a hybrid position requiring onsite for orientation and quarterly education at each region.
Essential Functions
- Perform detailed technical audit of CHHA and LHCSA records :
Conduct review of clinical documentation in patient medical record to ensure compliance with agency policies and procedures and regulatory guidelines.
Review identified areas of patient medical record for completeness and consistency.Enter review findings in an electronic database.Meet or exceed established productivity and timeliness expectations.Work as a team with co-workers to meet departmental and agency goals.Collaborate with clinical management, staff development, quality and compliance departments to inform of findings of audits, outcome measurements and notify of trends and potential education needs.Conduct education sessions with staff (1 : 1 or group setting) to inform of documentation deficiencies and provide corrective action as needed.Provide staff training for new Utilization Review initiatives and monitors the performance of assigned branches.Participate in the development of company Utilization Review guidelines and protocols.Keep abreast of pertinent industry utilization, regulatory and OASIS practice standards.Establish and promote positive, ongoing communication with company personnel.Maintain current knowledge and certification (when applicable) in areas of responsibility.Provide onsite education quarterly to review quarterly audit findings at each region.Other duties as assigned.This job description reflects management's assignment of essential functions; and nothing in this herein restricts management's right to assign or reassign duties and responsibilities to this job at any time.
Qualifications and Requirements
Required
Current, valid Registered Nurse license issued by NYS Department of Education.3 years Certified Home Health Agency experience.Excellent understanding of OASIS and Home Health regulations.Demonstrates excellent verbal, written, and critical thinking skills; must be able to be proactive and work well under pressure to meet deadlines and company needs.Demonstrates organizational and multi-tasking skills, as well as professionalism and discretion, with the ability to get along well with others in a work environment; must also demonstrate the ability to work independently; must be proactive, responsive and resourceful.Proficient in basic computer skills including Word and Excel.Must be comfortable learning new electronic medical records.Must have current, valid driver's license and reliable transportation.Preferred
LHCSA experience of 1 year or more.Bachelor's degree or higher.ICD-10 Home Health coding certification.OASIS Certification (i.e., HCS-O or COS-C).Work Environment
The Utilization Review Specialist is primarily in an office setting and may be exposed to outdoor conditions.
The working conditions are classified as sedentary work :
Sedentary work - Exerting up to 10 pounds of force occasionally, and / or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.Physical Requirements
The following is a description of the physical requirements on a daily basis for the Utilization Review Specialist. While performing the duties of the job the employee is regularly expected to :
StandHearWalkTalkStoop or kneelRepetitive motionThis is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed as assigned.
EOE / AA Minority / Female / Disability / Veteran
