Utilization Quality Review - VNA - Full Time - Days

Mohawk Valley Health System•City of Utica, NY

4d•Onsite

About The Position

The Quality Improvement Reviewer/Educator is responsible for developing, implementing, and evaluating Home Care Services quality improvement/staff education practices to ensure that quality patient centered home care services are provided. This includes the maintenance of, and adherence to each agency(s) policies and procedures governing Home Care Service agencies to ensure compliance with State & Federal Regulations.

Requirements

An associate’s degree in applied science with a current NYS registered nursing license
1 years of home care experience.
Valid New York State driver’s license

Responsibilities

In collaboration with the Director of Quality Improvement, maintains records and reports to support and document Utilization Review/Quality Improvement activities.
In collaboration with the Director of Quality Improvement, responsible for completing record audits for home care/member services per state and federal regulations.
In collaboration with the Director of Quality Improvement, responsible for compiling and maintaining audit record statistics and utilizes outcome reports to educate front line staff to improve patient/member outcomes.
In collaboration with the staff education supervisor, serves as educational resource to home care services clinical staff.
In collaboration with staff education supervisor, educates agency personnel on quality improvement and corporate compliance programs, clinical practice, and how their roles, responsibilities and actions relate to the process.
In collaboration with the staff education supervisor, educates home care services staff on clinical field practice per agency(s) regulations.
In collaboration with the Director of Quality Improvement, reports to the Professional Advisory Committee (PAC) on a quarterly basis.
Supports the Agency’s Compliance Program, coordinating compliance audits and report findings to internal compliance committee.
In collaboration with the Director of Quality Improvement, and Director of Patient Services, completes the process for receiving, documenting, tracking, investigation on all home care services complaints and coordinates information per agency standards.
Conduct review of claim data and medical records to make decisions on the coverage, medical necessity, utilization, and appropriateness of care per company policy and standards, as well as accepted medical standards of care.
Prepares monthly and/or quarterly reports of utilization management activities with statistical analysis performed.
Ensures that grievances and appeals are processed timely within the time frames of regulations and company policy.
Maintains a safe environment by adhering to the Agency’s Safety Program.
Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the agency(s).
In collaboration with the Director of Quality Improvement/Privacy Officer in developing, implementing, reviewing, revising, and monitoring facility-wide performance improvement activities.
Participates in the development and review of agency(s) policies & procedures.
Knowledgeable in the current methodology and practices and maintains awareness of changes in the regulations and requirements by accrediting bodies involving all home care services agency(s).
In collaboration with the education supervisor, completes joint competency field visits with staff per agency(s) regulations.
In collaboration with the education supervisor, completes electronic medical record (EMR) staff training per agency(s) needs.
In collaboration with the education supervisor, participates in clinical staff’s orientation process as scheduled.
In collaboration with the staff educator, completes and presents individual and group educational training sessions per agency(s) need under the direction of the staff education supervisor.
Performs other duties as required or assigned.