Home Care Quality Assurance Regulatory Specialist

The Quality Assurance Regulatory Specialist plays a pivotal role in overseeing the regulatory appeals process and the release of information, ensuring compliance with healthcare laws and regulations. This position assists the agency by providing timely, accurate, and legally compliant management of home care regulatory appeals, data collection, and release of patient information in adherence to applicable regulations.

Key Responsibilities:

1. Regulatory Appeals Oversight & Management:
• Manage the process of regulatory appeals related to home care services, including insurance denials, service coverage disputes, and reimbursement issues.
• Review denials and appeals documentation, develop strategies for appealing decisions, and submit detailed appeal packages to insurers, regulatory agencies, or other relevant entities.
• Track and report on the status of all appeals, ensuring that response timelines are adhered to and that all necessary follow-up actions are taken.
• Collaborate with internal teams to gather necessary medical documentation and clinical data to support the appeals process.
• Develop and maintain a system for tracking all appeals, including outcomes and timelines, to ensure accountability and transparency.
2. Release of Information (ROI) Management:
• Respond to internal and external requests for patient health information, ensuring appropriate authorization and documentation is received.
• Ensure all releases are properly documented and logged in accordance with regulatory requirements.
3. Quality & Performance Improvement:
• Collaborate with the Director of Performance Improvement to monitor the effectiveness of appeals processes and the release of information practices.
• Identify trends, patterns, and areas for improvement in both regulatory appeals and information release procedures.
4. Regulatory Compliance & Documentation:
• Maintain accurate records of regulatory appeals, outcomes, and release of information transactions in the appropriate systems.
• Keep up to date with changes in regulations and policies affecting home care services, regulatory appeals, and health information management.
5. Collaboration & Reporting:
• Prepare and present reports on regulatory appeals, release of information activities, and overall quality performance to the Director of Performance Improvement.
• Communicate effectively with various internal departments (clinical teams, billing, and compliance) to ensure smooth processing of regulatory appeals and release of information.

Qualifications:

• Education:
• Bachelor’s degree in healthcare administration, business, or a related field required.
• Certification in Health Information Management (e.g., RHIA, RHIT) or Regulatory Compliance is preferred.
• Experience:
• Minimum of 3-5 years of experience in healthcare, with a focus on regulatory appeals, release of information, and compliance.
• Experience working in home care or healthcare regulatory environments is strongly preferred.
• Skills & Abilities:
• Strong knowledge of regulatory compliance, including HIPAA, CMS regulations, and state-specific home care laws.
• Proficient in healthcare software systems (EHR) and Microsoft Office.
• Analytical and problem-solving skills, with the ability to identify trends.
• Excellent communication skills, both written and verbal, with the ability to create detailed reports.
• Ability to manage multiple tasks simultaneously in a fast-paced environment.

Work Environment:

• Primarily office-based, with occasional remote work flexibility.

At Catholic Health, your well-being comes first, with comprehensive compensation and benefits; our offerings go beyond the basics.  In addition to multiple medical plans, life insurance, generous paid time off and flexible spending accounts, we offer substantial tuition reimbursement, an employer funded pension plan and several savings plan options for your future.

Salary : $70,000 - $85,000