Hospice RN Reviewer

Under limited supervision, complete internal clinical record reviews to assess hospice’s compliance with its Corporate Compliance Program, policies and procedures, and controls to ensure all clinical operations conform to established hospice standards, hospice policy, state and federal regulations and industry compliance trends. Monitors and trends data from both internal and external sources to analyze and report significant trends requiring intervention to assist clinical operations in improving overall performance in patient outcomes and reimbursement.

Education:
Bachelor's degree from an accredited School of Nursing required; Master’s degree in Nursing preferred  

Experience:
Hospice experience and/or hospice auditing experience preferred.  5 years of diversified, progressive experience in acute care and/or other settings within the continuum; Hospice Case Management and utilization management experience preferred.  Centers for Medicare and Medicaid Services (CMS), Managed Care Organization (MCO), and/or other payer experience strongly preferred.
Skills:

• Advanced skills in clinical assessment of the patient/family
• Familiarity with all aspects of and criteria regarding the health care continuum
• Familiarity with the hospice Conditions of Participation, specifically related to Quality Assessment Performance Improvement (QAPI)
• Familiar with hospice billing requirements, specifically the Conditions for Coverage/Payment
• Knowledge of all third-party health care reimbursement systems and claim denial processes
• Knowledge of the CMS Conditions of Participation for long-term care facilities (e.g., nursing facilities and skilled nursing facilities)
• Knowledge of State and Federal Utilization requirements and denial/appeal regulations
• Skill in data analysis and reporting
• Skill in using computer software programs and personal productivity applications
• Advanced skill in oral and written communication
• Advanced skill in critical thinking
• Ability to resolve complex problems
• Ability to remain calm under pressure and intense time constraints

Licensures, Certifications

• Current state licensure as Registered Nurse

Physical Requirements

• Ability to travel to different locations; includes ability to drive, negotiate stairs and walkways
• Ability to sit, stand, walk, and pay close attention to detail

Working Conditions

• Normal office environment
• Must have reliable transportation

Conditions of Employment

• Maintain current licensure and certifications.
• If employed with the Hospice of Washington County, following 90-days of successful employment, one must begin the process for Pennsyvania state employment which includes Pennsylvania Access to Criminal History (PATCH) background check, Child Abuse Clearance, and fingerprinting.
• If employed with the Hospice of Washington County, must participate in mandatory on-call administrator rotation

Principal Duties and Responsibilities

• Assures the patient assessments are being done in a timely and thorough manner. (Must be able to give Feedback to Team Manager, Clinical Lead, F2F team, and education department about these patient assessments.)
• Assures that written documentation of these assessments is done at the right time, in the right location in the EMR, and in sufficient detail to be able to judge clinical eligibility for hospice initially and on an on-going basis and appropriate level of care (GIP, Respite and Continuous care). Must be familiar with LCD's, CMS guidance and Weatherbee tools.)
• Must be familiar with REMOTE CLIENT, AMBULATORY and INPATIENT Modules of EPIC (majority of the work is electronic chart review)
• Participate in feedback meetings, assessment/documentation performance improvement work, and supervision of others hired to help with the chart reviews.
• Assist with drafting/writing the response letters to ADR and appeals process, all the way to the ALJ
• Participates in the development and implements process improvement of the hospice Assessment, Documentation and Utilization Review Model (i.e.: readmissions, care transitions, risk assessments, and care integrations)
• Maintain working knowledge of CMS conditions of participation and Medicare billing requirement.
• Responsible for daily coordination of the nurse internal review team.  Provides regular status reports to the Director.
• Manages scheduling, staffing, and daily assignment of staff
• Assures timely and complete documentation of assessments, plans, and interventions within the department