Our culture and people are what set us apart from other post-acute care providers. We’re dedicated to the growth and development of our team to set them up for success. We CARE for our patients like they are our own FAMILY.               

Note: The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), require COVID-19 vaccinations for all Medicare and Medicaid certified providers.  Based on this regulation, all of our employees must be fully vaccinated or have a valid exemption.

SUMMARY:

The Utilization Review Specialist reviews patient charts and collects data to identify areas in need of improvement both clinically and administratively that directly affect patient care and quality outcomes. The Utilization Review Specialist is responsible for development and implementation of process improvement, Oasis Review, Orders Processing, or BOT support as identified by primary role Responsibility and business need. The Utilization Review Specialist complies with all legal, Medicare & private insurance and company rules and regulations.

QUALIFICATIONS & ATTRIBUTES:

• Registered Nurse (RN) with Current State Licensure to meet business needs of the department, including but not limited to: OH, FL, MI, and Virgina

• Minimum of 3 years in Home Care or in quality Improvement

• Knowledge of CMS guidelines, Quality Metrics, Star Measures, Outcome Measures, HHCAHPS, HHVBP, Oasis Rules and Guidelines, Clinical Best Practices

• Attend in-service trainings and mandatory meetings.

• Comfortable learning new software and database systems

• Ability to use Microsoft Office with extensive experience with Word and Excel programs

• Observant and detail oriented

• Ability to multi-task and prioritize

• Ability to track and analyze data

• Ability to follow directions and work as a team member and maintain effective communication.

• Adhere to ASHN Vision, Mission, and Beliefs

AREAS OF RESPONSIBILITY:

• Understanding of Regulatory Standards and Agency Policies and Procedures: Quality assurance professionals must be knowledgeable about CMS guidelines and submission times, Quality Metrics, Star Measures, Outcome Measures, HHCAHPS, HHVBP, Oasis Rules and Guidelines, Clinical Best Practices.  To include but not limited to: VPE, LUPA, readmission rates, Quality Visit guidance, PDGM/Insurance Guidelines

• Analytical Skills: Quality assurance professionals need strong analytical skills to review and assess data, identify trends, and detect areas for improvement.

• Patient-Centered Approach: A focus on patient outcomes and safety is integral to quality assurance, as patient satisfaction and safety are central to healthcare quality. Reviews orders, utilization management, assessment, plans of care, and oasis for accuracy and patient safety with adherence to all regulations, guidance, and legal and government regulations.

• Documentation: Quality assurance roles often involve record-keeping and documentation of quality-related data and processes

• Critical Thinking: The ability to evaluate complex situations, identify problems, and propose effective solutions is essential for quality assurance work.

• Computer Skills: Proficiency in using quality management software, data analysis tools, and BOT support as appropriate.

• Interpersonal Skills: Quality assurance professionals often work with diverse teams, so strong interpersonal skills are essential. 

• Problem-Solving: The ability to identify issues, root causes, and develop strategies to address them is fundamental in quality assurance. Interdepartmental Collaboration with field clinician as needed.

• Attention to Best Practices: Keeping informed about evidence-based practices and incorporating them into quality improvement efforts is important.

• Continuous Learning: Staying up-to-date with evolving healthcare practices, regulations, and quality improvement methodologies is critical.

• Ethical and Legal Awareness: Understanding ethical and legal issues in healthcare is crucial when reviewing and improving care quality.

• Read and Adhere to all Agency Policies and Procedures and follow employee Handbook Guidelines

• Maintain or Exceed Productivity expectations.

• Other duties as assigned.

Health Requirements: Employee must be free of physical/medical conditions that would limit or restrict their ability to perform the job functions listed below.  Bloodborne Exposure risk is none.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Below are minimal knowledge/physical requirements of this position.

Constantly (66%-100%):

Reading, Speaking, Writing English

Communications Skills

Computer/PDA Usage

Hand/finger dexterity

Hearing/Seeing

Vision for close work

Talking on the phone

Hearing on the phone

Talking in person

Hearing in person

Frequently (34%-66%)

Walking

Bending

Standing

Sitting

Stretching/Reaching

Driving

Stooping (bend at waist)

Occasionally (2%-33%)

Lifting up to 50 lbs. with or without assistance

Distinguish smell/taste

Climbing

Rarely (1% or less)

N/A

We’ll help you put your passion for patient care to work.  Apply today!

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

We are an Equal Opportunity Employer.