Quality Review & Utilization Specialist

Job Title: Quality Review & Utilization Specialist DEPARTMENT: Quality Review LOCATION: Home Care-330 Monroe Ave, Rochester, NY HOURS: Per Week: 40 Hours SCHEDULE: 8:30am-5:00pm Monday-Friday Position Summary: Under the direction of Leadership, coordinates/performs all activities related to the RRHS utilization review (UR) program and quality record documentation monitoring. A primary responsibility of this position (in addition to chart review for UR) is the timely review/approval of Start of Care Assessments including the Comprehensive Assessment, Physician Plan of Care, OASIS, and home health diagnosis coding. Reviews clinical documentation to ensure adherence to State and Federal regulations, payer requirements, and OASIS CMS guidance. Provides superior customer service by modeling the Brand Promise and the Core Values. Key Responsibilities: - Responsible for ongoing documentation and chart audit: to include but not limited to home health diagnosis coding, OASIS Start of Care, Resumption of Care, Recertification, and Discharge chart audits, 485 audits, Plan of Corrections audits, compliance audits, etc. - Responsible for maintaining current knowledge of home health diagnosis coding and OASIS review. Participates in educational opportunities provided to the team. - Responsible for the Quarterly Utilization and Review (U/R) process to include timely completion of required number of audits, documentation of audit results. - Participates in the ongoing regulatory review, identifies and researches new regulations as assigned. - Participates in the organizations policy and procedure review process as assigned. - Develops new policies as assigned. - Performs drug regimen reviews as requested by leadership. - Performs inter-rater visits as requested by leadership. - Participates in education of staff to include but not limited to quality initiatives, OASIS in-services, Policy and Procedures, Orientation. - Facilitates and/or participates in ongoing committees or groups. - Represents the organization to appropriate Community Groups. - Collaborates with clinical practice and education nurse to ensure all quality and compliance activities are coordinated and based on data. - Performs co-visits or billable patient visits as needed, as requested by leadership. - Other duties as assigned Desired Attributes: COS-C certification preferred. Home Health Diagnosis Coding Certification preferred. BSN or RN with BS in related field preferred 1 year of home care quality/regulatory experience preferred. 1 year of OASIS experience preferred. Minimum Qualifications: RN Nursing Diploma required, ASN preferred. 2-4 years of home care experience. Required Licensure/Certification Skills: Current NYS RN license. Current N.Y.S. Driver's License Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran EDUCATION: BS (Required) LICENSES / CERTIFICATIONS: BLS - Basic Life Support - American Heart Association (AHA), NYS DL - valid New York State Driver's License - New York State Department of Motor Vehicles (NYSDMV), RN - Registered Nurse - NYS Office of Professions PHYSICAL REQUIREMENTS: Sedentary - Sedentary roles are primarily office-based and require prolonged sitting (67–100% of the workday) with minimal physical effort and lifting limited to under 10 lbs. Fine motor skills are necessary for computer work, writing, and telephone use, supported by clear visual and auditory ability. Cognitive and emotional demands are high due to extended concentration, frequent interruptions, independent decision-making, and information processing. Although physical exposure is low, administrative areas within healthcare environments may occasionally involve contact with infectious agents. Some roles may require flexible hours, TB screening, or a valid driver’s license. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations. PAY RANGE: $75,700.00 - $101,000.00 CITY: Rochester POSTAL CODE: 14607 The posted pay range is a good faith representation of potential base pay for this position. It may be modified in the future and eligible for additional pay components. Individual annual salaries/hourly rates could vary based on position details and FTE. Pay is determined by considering factors including, but not limited to, experience, relevant qualifications, specialty, internal equity, locations, and contracts. Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.