Quality Assurance / Utilization Review Specialist

Less than 5 years experience  •  Misc. Healthcare

Salary depends on experience
Posted on 06/26/17
Less than 5 years experience
Misc. Healthcare
Salary depends on experience
Posted on 06/26/17

Quality Assurance/Utilization Review Specialist

Job Summary: 
Under the direction of the Senior Director of Home Care and within established agency policy and procedure, the Quality Assurance/Utilization Review Specialist serves as a role model and educator for quality care by demonstrating an advanced level of knowledge in regulatory and compliance affairs.  The Quality Assurance/Utilization Review Specialist also investigates patient care issues when quality of care is potentially jeopardized, assists with orientation of new staff, and assesses staff skills for documentation of care and communicates evaluation to the Senior Director of Home Care. The Quality Assurance/Utilization Review Specialist develops tools to support cost-effectiveness, efficient, quality care and integrates these tools into practice, by assisting with the development of clinical pathways, and assisting with integration of outcome measures


• Provides superior customer service to internal and external clients, customers and patients
• Submits informational data to Senior Director of Home Care based on educational and quality improvement activities
• Audits clinical records for appropriate utilization of services, quality outcome measurement, standards of practice and to ensure regulatory compliance
• Works in collaboration with Senior Director of Home Care for the development, implementation, and auditing of tools and systems for bench marking, forecasting, and planning, using OASIS/educational data.
• Participates in the development and implementation of processes to investigate Adverse Events
• Assists in reviewing admission charts, visit notes, recertification and discharge documentation to identify learning needs of staff to ensure compliance with agency and regulatory standards
• Formulates and plans in collaboration with the Senior Director of Home Care, the identification of documentation and OASIS development  needs
• Participates in the implementation and evaluation of the agency quality program to ensure quality outcomes are achieved.
• Reviews OASIS and visit notes to ensure accuracy in documentation, appropriate diagnosis sequencing, and diagnosis coding, as governed by relevant rules and regulations.
• Assists with developing and providing educational programs for direct care staff that will improve individual and group performance on OASIS/documentation.
• Assists in reviews of patient and medical billing information and prepares responses to request for additional information from Medicare (ADR), denials, and third party liability activity when requested.
• Completes required clinical record review as requested by state and federal agencies.
• Assists in maintaining and promoting Joint Commission standards.
• Participation in orientation and ongoing educational programs
• Assists in the preceptor program development and implementation and provides ongoing evaluation on effectiveness, and revisions as indicated by staff needs
• Acts as a resource to new employees throughout the orientation process
• Participates in carrying out general functions of the Quality Department.
• Represents the agency on committees, sharing and gathering appropriate information
• Follows agency policy and procedures and adheres to standards of practice within agency guidelines
• Performs other duties as required


• Graduate of an Accredited School of Nursing
• Current RN licensure from the Massachusetts Board of Nursing, BSN preferred
• Demonstrated competence and satisfactory performance with direct patient care in a community health or medical/surgical setting for a minimum of three years
• Experience in quality management and utilization review preferred
• Possesses strong working knowledge of third party reimbursement as well as home health regulatory requirements
• 4 yrs experience as an RN, preferably in Home Care and 1 yr in a performance improvement role
• Ability to teach and role model for colleagues
• Demonstrated organizational skills, self directed and independent in fulfilling role obligation
• Coding and OASIS experience and certification preferred

Req Number: 39764

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