Quality Improvement Specialist PT Days
About The Position
Under general direction and according to established policies and procedures, the Quality Improvement Specialist monitors patient care for quality assurance, utilization review, and risk management activities. The role determines the appropriateness and medical necessity of admissions, continued hospital stays, and ancillary services. It may include pre-authorizations, concurrent review, and retrospective review audits. The specialist may troubleshoot patient issues with Patient Management, as needed, and reviews and monitors patient medical records for complete, timely, and accurate entries. The role communicates with third-party payors and develops appeals to overturn adverse payment decisions. It also provides technical assistance to clinical and administrative staff on developing quality improvement indicators and monitors, measurement methodology, and charting techniques; conducts special studies; and prepares reports of findings. The specialist may participate in developing, educating, and maintaining the DMC Continuous Improvement Program. The role facilitates preparation for JCAHO and other licensing-body accreditation requirements and may develop and present in-services to clinical and administrative staff about documentation and review findings.
Requirements
- Bachelor’s degree in Nursing, Medical Records, or a health care field, or an equivalent combination of education and/or related experience.
- Two to three years of progressively more responsible clinical and/or Quality Assurance/utilization Review experience.
Nice To Haves
- Registered Nurse preferred.
- Coursework and experience in research statistics and quality improvement methodology, including chart control techniques, preferred.
Responsibilities
- Monitor patient care for quality assurance, utilization review, and risk management activities.
- Determine the appropriateness and medical necessity of admissions, continued hospital stays, and ancillary services.
- Perform pre-authorizations, concurrent reviews, and retrospective review audits, as applicable.
- Troubleshoot patient issues with Patient Management, as needed.
- Review and monitor patient medical records for complete, timely, and accurate entries.
- Communicate with third-party payors and develop appeals to overturn adverse payment decisions.
- Provide technical assistance to clinical and administrative staff regarding quality improvement indicators and monitors, measurement methodology, and charting techniques.
- Conduct special studies and prepare reports of findings.
- Participate in developing, educating, and maintaining the DMC Continuous Improvement Program, as applicable.
- Facilitate preparation for JCAHO and other licensing-body accreditation requirements.
- Develop and present in-services to clinical and administrative staff regarding documentation and review findings, as necessary.
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What This Job Offers
Job Type
Part-time
