Quality Review Nurse

: Reviews documentation, communicates with supervisors, and performs documentation audits. Education

• Bachelor's degree or an equivalent combination of education and experience required

Experience

• 3-4 years Home care nursing experience; quality assurance/utilization review experience preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia, and the State of Maryland or Virginia required

Knowledge, Skills, and Abilities

• Extensive knowledge of Medicare and TJC guidelines, OASIS, and ICD-10 coding guidelines.
• Attention to detail.
• Basic computer skills preferred.

• Contributes to the achievement of established goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Completes annual Code of Conduct, Compliance, and other mandatory training. Complies with governmental and accreditation regulations.
• Assesses documentation for compliance with agency standards, policies and procedures, governmental and accreditation regulations.
• Assists in determining if the order is required, appropriateness of order content, and that the name(s) of the correct physician(s) is assigned to the order for all 485s and verbal orders to assure timely completion and accuracy.
• Codes and sequences diagnoses including co-morbidity diagnoses pertinent to the home care episode.
• Completes corrections to OASIS verification reports and assessments for timely billing.
• Identifies clinician education needs. Develops and participates in education to all clinical staff related to documentation issues.
• Maintains effective relationships with other departments. Participates in multidisciplinary quality and service improvement team meetings and on committees as assigned. Enhances growth and development and enriches personal knowledge and skill through participation in educational programs and affiliations.
• Maintains ongoing communication with the Operations Director and supervisor to provide feedback, discuss new developments, and exchange information regarding staff problems with documentation compliance issues.
• Participates in process/performance improvement activities, and in updating the quality review process and tools as needed.
• Performs audits as assigned for appropriateness and completeness of care according to Plan of Care and regulatory requirements. Assists in preparation for and support of accreditation surveys. Conducts chart audits for performance improvement activities.
• Performs workflow tasks as assigned.
• Provides feedback and input related to policies and procedures to comply with new and existing regulatory standards.
• Provides a skilled review of clinical charts in utilization review/pre-post billing audits to ensure meeting agency policy/program and regulatory requirements. Includes written explanation when deficient areas identified. Assists in identifying appropriateness in billing and makes recommendations for improvement.
• Responds to urgent requests in a timely manner for all documentation and care needs.
• Reviews admission Assessments, ROC/recerts, transfers, and discharges for accuracy appropriate skilled care needs. Communicates with staff regarding deficient documentation. Utilizes reports to monitor and lock assessments timely.
• Reviews all OASIS discharges from all agencies for accuracy, as assigned.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.