November 15, 2024

Century Homecare LLC

Worcester

FULL TIME

Quality Assurance and Prior Authorization Specialist – Home Health

Why join our growing team at Century Homecare?

Team-oriented culture
Friendly work environment
Competitive pay
Benefits

Job Description
We are looking for a Nurse (RN or LPN) to join the Clinical Prior Authorization (PA) and Quality Assurance (QA) Department at Century Homecare. The QA/PA Specialist will audit all OASIS and clinical documents for accuracy and consistency, process service authorization requests for home care services, and collaborate with clinicians to address documentation issues and ensure compliance with relevant regulations.
The QA/PA Specialist is an integral member of the company’s compliance team, responsible for training and re-training clinicians to document correctly and improve compliance. The Specialist will also be the lead for clinical orientation and training of new hires.
Responsibilities for this role include:
Staff Orientation & Training
- Develop and implement clinical orientation curriculum for new staff.
- Provide training on documentation best practices, compliance, and patient advocacy.
- Conduct ongoing training for all employees regarding documentation and performance improvement (P.I.) programs.
- Train clinicians and staff on accurately completing service authorization request forms.
Patient Advocacy
- Consult with physicians to ensure safe and quality patient care.
- Liaise with clinicians to obtain accurate data for submissions and ensure proper documentation.
- Accurately code patients' medical information for reimbursement.
- Process documentation to expedite approvals and ensure follow-up.
- Review and verify the completeness and accuracy of information and supporting documents.
- Manage pre-authorization requests and monitor them closely.
- Process referrals and submit medical records to insurance carriers for prior authorization.
- Assist with managing denials and appeals for insurance approvals.
- Participate in patient case conferences to understand patient needs.
Compliance
- Conduct ongoing chart audits for compliance and improvement areas.
- Review of OASIS documents ensuring compliance with home health Medicare and Medicaid standards.
- Complete ICD-10 coding for all relevant OASIS assessments.
- Review Plans of Care and Physician Orders for appropriateness.
- Assist in designing and implementing quality improvement projects and auditing patient records.
- Stay updated on industry trends, regulations, and requirements.
- Analyze Medicaid and other payor prior authorization regulations to improve workflow.
- Gather patient data to support medical needs and complete service authorization requests accurately.
- Assist in validation audits for Medicare and other government programs.
- Maintain audit-related documents for annual audits.
- Coordinate and participate in Quality Assurance and Service Authorization meetings.
- Manage Service Authorization projects to enhance efficiency.
- Participate in Continuous Quality Improvement (CQI) committee meetings to support quality initiatives.
Qualifications:
- Must have at least 2 years' experience in a Home Healthcare or healthcare institutional setting of which one year is PA/QA experience in a home health setting.
- Must have a thorough understanding of home health documentation requirements per Medicare and Medicaid regulations.
- Must be available to work in office between 8:30AM - 5:00PM (hybrid option can be discussed).
- Licensed Nurse in good standing in the State. (Preferably RN or an LPN with an equivalent combination of experience and proficiency in the areas of responsibility.)
- Excellent computer skills to input and retrieve clinical information.
- Willingness to grow and develop as a leader to effectively accomplish the department goals and support the company’s vision, mission, and values.
This is a salaried position starting from $35 per hour (annualized).
Job Type: Full-time
Pay: From $35.00 per hour
Benefits: