Clinical Services Review Nurse UM Review RN in Augusta, GA at US CareNet

Date Posted: 1/10/2020

Job Snapshot

  • Employee Type:
  • Location:
    Augusta, GA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:

Job Description

 Job Description Summary:

The Clinical Services Review Nurse is a qualified professional who performs ongoing client/patient chart and other supporting documentation reviews and audits to ensure quality and compliance as well as occasional on-site agency assessments. These responsibilities will be carried out to ensure compliance with agency requirements, established policies and state and federal guidelines under the supervision of the Director of Clinical Services.

Essential Job Functions/Responsibilities:

 A.    Performs prospective reviews of Plans of Care (POC), OASIS admissions, resumptions and re-certifications and processes workflow in medical records (EMR) system as assigned.

B.    Ensures appropriate ICD-10 Coding and sequencing as it relates to the patient‘s medical condition, including any co-morbidities and current guidelines as they relate to billing purposes. 

C.   Contacts offices to resolve documentation, coverage and compliance issues.  Solicits needed information required to complete the overall Utilization Management and Review process.  

D.   Serves as a liaison between Operations leadership, agency management and the Clinical Services department to identify training needs on current systems and processes or problematic trends in clinical documentation. 

E.    Identifies enhancements and improvements to the clinical documentation process which further advance the functionality of the process and works with internal departments and external vendors to develop enhancements.  Serves as a resource for expedited problem identification and resolution related to the clinical documentation process. 

F.    Conducts prospective and retrospective reviews of admissions and re-certifications to ensure appropriateness, completeness and compliance with established state and federal guidelines.   

G.   Ensures RAPS are completed in a timely manner and is compliant with Medicare regulations. Facilitates processes for final claims.   

H.   Keeps current on all regulatory changes that affect state and federal home health services.  Attends conferences as assigned and shares information with Clinical Operations staff. 

I.     Reviews visit episode management for appropriateness as per care guidelines and patient conditions. 

J.    Participates as needed in New Employee Orientation, and other web-based orientation programs and supplementary staff educational venues.

K.    Assists clinicians in setting priorities, appropriate goals and developing the plan of care. 

L.    Responsible for compiling and sharing daily, weekly and quarterly reports. 

M.   Acts as a back-up for any agency operations vacancies.

Position Qualifications:

 1.    Registered Nurse (RN) required. 

2.    Obtain and maintain RN licenses for all States serviced by the organization. 

3.    Working knowledge of state and federal regulations for home health agencies and an understanding of home health policies.  

4.    Two (2) years of home health or Medicare reviewer experience preferred. 

5.    HCS-D (Home Health Coding Certification) and COS-C (Certified OASIS Specialist-Certified) Certification strongly preferred. Will be required to obtain COS-C certifications within 6 months of hire. 

6.    Demonstrated strength in documentation skills, both oral and written. Demonstrated ability to motivate and educate others. 

7.    Working knowledge of computer systems. 

8.    Ability to complete assignments timely and meet organizational deadlines. 

9.    Ability to adapt to changing organizational needs.  

10.  Disposition to work harmoniously with departmental staff, as well as other agency employees and clients. Excellent customer service skills. 

11.  Detailed-orientated and able to work independently to meet deadlines. 

12.  Position requires occasional travel to agencies for on-site reviews of agency clinical and operations staff and/or to assist in covering operations vacancies.