Description
Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details: Work where every moment matters.
Every day, almost 30,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network as a Quality Improvement Coordinator.
Hartford HealthCare at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years. Our Person-Centered Care Model allows our employees to learn and grow within our organization, all while providing integrated support to the patient. As part of Hartford HealthCare, we leverage cutting edge technology to provide quality care in our client's home. Most importantly, our employees are appreciated for the real differences they make in both the lives of their clients and their clients' families.
Basic Purpose of the Position:
Manages appeals at the branch level including clinical documentation review, training, and guidance of clinical staff to ensure accurate reimbursement, regulatory compliance and the delivery of outcome-based, quality, cost effective care.
In general, most of the time will be spent in the following activities:
Monitor Advanced Beneficiary Notices and denials as it relates to medical necessity requirements.
Identify and evaluate denials to determine specific issues and patterns that need to be addressed with the facility.
Investigate all payer denials and take appropriate action including but not limited to appeals, corrected billing
and chart reviews.
Document patient accounting system with all denial activity and actions taken.
Compile monthly denial reports.
Maintain all data elements related to denials in the Compliance 360 module.
Other duties as assigned by supervisor
Facilitates record audits and process of care investigations, trends outcome data (satisfaction, utilization and clinical), develops and implements plans of action to ensure quality improvement, reimbursement and regulatory compliance.
Reviews, calculates, and analyzes identified data processed by other team members as it relates to clinical documentation and quality of care. Develops and facilitates performance improvement teams and quality initiatives across the agency.
Assist Quality teams with adverse event investigations, root cause analysis and development of best practices for the agency.
For clinicians identified by Clinical Team Manager and Clinical Development Specialists provide reviews and processes certification/recertification and resumption of care orders ensuring accurate documentation and appropriate development of the plan of care.
Collaborates with Clinical Team Manager and other case managers to support the Patient Centered Care Model including case conferencing, review of documentation and focused education to the clinical team.
Provides staff guidance in making clinical and case management decisions that are cost effective and focused on clinical outcomes and operational performance indicators.
Conducts education and training sessions related to utilization, reimbursement and regulatory compliance.
Performs monthly pre-billing audits for Medicare, Medicare and Hospice
Takes the lead on Additional Documentation Requests (ADR), government and payer audits to ensure documentation supports payer requirements and to ensure submission is timely
Develops training to staff to improve clinical documentation
Ensures standard work minimizes risk for denials
Participates in quality assurance audits, audits, appeals and committees & projects as needed.
Demonstrates the ability to research regulations and legal requirements on reimbursement issues and to train staff appropriately.
Demonstrates the ability to work well with others and to educate clearly and concisely.
Maintains a flexible schedule to meet the needs of the agency.
Qualifications
Licensure: Registered Nurse with a license to practice in the State of Connecticut
Education: Graduate of an Associates degree or diploma program in Nursing; graduate of National League of Nursing-approved BSN program, preferred
Experience: Three years clinical homecare experience. Managed care or case management experience required. Proficient in Oasis, record review, home care regulations and use of quality tools. Computer literate. Demonstrated ability to work with teams and individuals in providing clear, understandable direction and guidance. Excellent written and verbal communication skills.
We take great care of careers
With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge - helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.
