Quality Review Specialist at Optum

Explore opportunities with Shared Services, a part of LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here. Join us and embrace a culture of Caring. Connecting. Growing together.

As the Quality Review Specialist, you will be responsible for the timely review of plan of care and OASIS time points in the electronic medical record to ensure accuracy of OASIS items, documentation, and utilization for quality and outcome management through clinician collaboration and implementation of best clinical practices. You will also identify opportunities for improved OASIS accuracy and reporting these to OASIS clinical staff during scheduled staff meetings.

Primary Responsibilities

• Thoroughly reviews the medical record as part of the OASIS review process and recommends the most accurate codes, adhering to official OASIS guidelines as approved by the Centers of Medicare and Medicaid Services (CMS)
• Reviews plan of care; recommends edits to clinician and makes edits to the plan of care based on updated provider orders
• Consistently engages directly with clinicians to improve accuracy of OASIS assessments, ensure proper development of the plan of care relevant to the primary focus of care and the patient assessment, and assure clinically appropriate discharges
• Assesses clinical documentation to ensure that it supports the recommended OASIS and POC changes
• Consults the clinician for clarification, via electronic alerts, when conflicting or ambiguous documentation is present, and abides by the clinician's acceptance or declination of changes
• Provides OASIS education to clinicians when opportunities arise (e.g., provide pertinent official OASIS guidelines or conventions when the clinician questions a change recommendation)
• Maintains accurate and timely review of OASIS time points and all related interdisciplinary documentation via the workflow in the electronic medical record (EMR) for timely OASIS locks and submission to the Centers for Medicare and Medicaid (CMS)
• Develops and implements training based on evaluated competencies in documentation and clinical practice, edits from Strategic Healthcare Programs (SHP) alerts, and SHP reports for specific outcomes, adverse events, and utilization reports in conjunction with the OASIS Analyst, Clinical Director (CD), Executive Director (ED), or PI Coordinator
• Collaborates with regional PI coordinator and agency to facilitate initiatives to improve quality outcomes and agency ratings
• Identifies educational trends for agency and/or per clinician and discusses with Clinical Director and Quality Review Supervisor to further train/educate staff and improve OASIS accuracy. Reports to supervisor and operational leadership any continued lack of improvement or engagement from clinicians
• QR Specialist may be required to relocate to a nearby office and perform PCM workflow occasionally
• QR specialist will continue to participate in on-call rotation for their originating agency if they were in the on-call rotation prior to QR role
  
  

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• Current CPR certification
• Current Driver's License, vehicle insurance, and access to a dependable vehicle or public transportation
• Current and unrestrictive RN, PT, ST, or OT licensure in state of practice
• Current COS-C or completion within 90 days of position effective date
• 1+ years of Home Health experience as RN, PT, ST, or OT
• Ability to analyze OASIS data at a high level, and to accurately interpret and apply current OASIS guidelines, Conditions of Participation, and PPS guidelines to find opportunities for training and development
  
  

Preferred Qualifications

• Effective verbal and written communication skills
• Solid computer skills with proven ability to use MS Office applications, OASIS review software, and clinical documentation software as well as reports available in these programs
• Exceptional organizational skills
  
  

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $71,200 to $127,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.