Clinical Quality Specialist

Company:

Compassus

 

Position Summary

The Clinical Quality Specialist is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Clinical Quality Specialist is primarily responsible for ensuring the accurate entry of all Start of Episode and OASIS forms for patient charts. S/he processes Home Health Director of Clinical Services workflows.

Position Specific Responsibilities

• Completes or reviews all client medical records regarding OASIS.
• Executes all OASIS reviews on a timely basis.
• Assures compliance with OASIS time frames as required by law.
• Completes OASIS activities as appropriate in conjunction with field staff.
• Reviews and processes the Home Health Director of Clinical Services workflow as assigned, including tasks related to start and resumption of episode, OASIS review and utilization.
• Performs other duties as assigned.

This role will also support Pre-Claim Review (PCR) Duties and Responsibilities

• Conduct comprehensive chart reviews for Medicare patients requiring Pre-Claim Review to ensure full compliance with CMS regulations, Medicare coverage criteria, Home Health Conditions of Participation (CoPs), and Compassus policies.
• Validate that all eligibility requirements are met, including accurate payer verification, homebound status, skilled need, and documentation supporting medical necessity.
• Review and confirm compliant Face-to-Face (F2F) documentation ensuring encounter timing, provider type, and narrative content align with CMS requirements for home health certification.
• Examine OASIS assessments, Plan of Care (POC/485), visit notes, and supporting clinical documents to ensure internal consistency and alignment with the patient’s condition, skilled needs, and ordered services.
• Ensure all orders, frequencies, and durations are appropriate, medically necessary, and clearly supported by physician documentation and clinical narratives.
• Identify documentation gaps, inconsistencies, or compliance risks and communicate required corrections or clarifications to clinicians, intake, medical records, or leadership in a professional and solution-focused manner.
• Prepare complete, accurate PCR submission packets including F2F, OASIS, POC, and initial visit notes, ensuring all elements are legible, properly signed, and formatted per MAC requirements.
• Submit PCR requests through the applicable Medicare Administrative Contractor (MAC) portal (e.g., Palmetto, CGS), ensuring accuracy in NPI selection, episode type, billing codes, and documentation attachments.
• Monitor the status of PCR submissions and respond promptly to Additional Documentation Requests (ADRs) or reviewer inquiries, gathering and submitting supplemental documentation within required timeframes.
• Track, trend, and accurately record PCR outcomes, including affirmation status, denial reason codes, turnaround times, and documentation deficiency patterns.
• Collaborate with clinical, intake, billing, and quality/compliance teams to resolve issues related to documentation, eligibility, or submission accuracy.
• Participate in quality improvement efforts by identifying process gaps, recommending solutions, and contributing to the development of training materials, job aids, and workflow enhancements.
• Maintain a high level of accuracy and attention to detail while working in a fast-paced, deadline-driven environment with frequent regulatory updates.

Education and/or Experience

• Associate or Bachelor's degree in Nursing required.
• One (1) year experience in home health care required.
• QA experience in home health care preferred.
• Prior experience with electronic medical records preferred.

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, te