Clinical Quality Reviewer

Care New England Health System•Warwick, RI

About The Position

The Clinical Quality Reviewer supports Home Health and Hospice quality, compliance, regulatory, and performance improvement activities through focused review of nursing, rehabilitation, hospice, and interdisciplinary clinical documentation. They evaluate plans of care, OASIS assessments, HOPE assessments, coding and documentation accuracy, functional and clinical outcomes, and quality measure performance to promote accurate, compliant, patient-centered care across both service lines. They serve as a clinical resource to staff and leadership by identifying documentation improvement opportunities, providing feedback to support clinical excellence, assisting with corrective action initiatives, and promoting compliance with federal, state, accreditation, and organizational standards. The Clinical Quality Reviewer analyzes clinical and quality data to identify trends, support performance improvement efforts, reduce risk, and improve patient outcomes. They collaborate with managers, educators, clinicians, medical records, rehabilitation staff, and quality leadership to support regulatory readiness, quality initiatives, survey preparedness, and continuous improvement activities.

Requirements

Bachelor's Degree Required; Field of study: nursing, physical therapy, occupational therapy, speech-language pathology, or a related clinical field. Advanced degree preferred when required for professional licensure or practice.
Minimum 3 to 5 Years of clinical experience in home health and/or hospice.
Experience with clinical documentation review, OASIS, quality improvement, utilization review, regulatory compliance, or staff education required.
Home Health, Hospice, CMS quality reporting, and accreditation survey experience preferred.
Current unrestricted Rhode Island license or other authorization to practice as a Registered Nurse, Physical Therapist, Occupational Therapist, Speech-Language Pathologist, or other applicable licensed clinical professional required. Additional licensure, certification, driver’s license, automobile insurance, or BLS certification is required only when necessary for assigned duties, travel, or patient-facing responsibilities.
Strong knowledge of Home Health and Hospice clinical practice, documentation, quality reporting, and regulatory compliance.
Working knowledge of current CMS Conditions of Participation, OASIS guidance, HOPE guidance, HHQRP, HQRP, HHVBP, QAPI, and applicable accreditation and state requirements.
Knowledge of home health nursing practice, rehabilitation practice, hospice care, functional and clinical assessment, standardized measurement, goal development, symptom management, care planning, utilization, and discharge planning.
Ability to review clinical records objectively, interpret regulations and guidance, identify trends, and make practical recommendations.
Strong analytical, organizational, written communication, verbal communication, and facilitation skills.
Ability to manage assigned reviews independently, maintain attention to detail, meet deadlines, and protect confidential information.
Proficiency with electronic medical records, Microsoft Office applications, quality reporting systems, and audit or data tracking tools.

Nice To Haves

Home Health, Hospice, CMS quality reporting, and accreditation survey experience preferred.
Advanced degree preferred when required for professional licensure or practice.

Responsibilities

Conducts concurrent and retrospective reviews of Home Health and Hospice clinical records to assess documentation quality, accuracy, timeliness, medical necessity, and compliance with regulatory and organizational requirements.
Reviews plans of care and interdisciplinary documentation to ensure clinical appropriateness, care coordination, regulatory eligibility requirements, and alignment with patient needs, goals, and services provided.
Identifies documentation gaps, compliance risks, and opportunities to improve quality, patient outcomes, safety, and operational performance.
Reviews OASIS assessments and supporting clinical documentation for accuracy, completeness, clinical consistency, regulatory compliance, and alignment with CMS requirements.
Supports HHQRP and HHVBP performance through review of quality measures, data integrity, assessment submission readiness, outcome trends, and documentation practices that impact patient outcomes and organizational performance.
Reviews HOPE assessments and hospice documentation for accuracy, completeness, timeliness, regulatory compliance, and consistency with the hospice plan of care, including admission, update, and discharge timepoints.
Supports HQRP compliance and hospice quality improvement initiatives through review of quality measures, data integrity, submission readiness, symptom management documentation, interdisciplinary care planning, and patient/caregiver experience outcomes.
Supports survey readiness, accreditation activities, policy review, regulatory compliance, staff feedback, and quality improvement efforts through collaboration with clinical, operational, and educational leadership as needed.
Analyzes audit results, quality data, and performance trends to identify improvement opportunities, support system learning, and recommend corrective or preventive actions as needed.
Supports the Director of Organizational Excellence in the planning, implementation, monitoring, and evaluation of QAPI and performance improvement initiatives to enhance quality, patient outcomes, and regulatory compliance as needed.
Participates in committees, case reviews, focused audits, special projects, and staff education as requested.
Assists with review of quality reports, Care Compare results, star ratings, patient experience findings, and action plans within the assigned scope as requested.
Performs other related assignments or functions in support of organizational excellence.