Clinical Care Utilization Specialist

All Saints Hospice

The primary role of the Clinical Care Utilization Specialist is to ensure timely and accurate creation and completion of the Plan of Care/485 document for claim submission and reimbursement.  The Clinical Care Utilization Specialist (CCUS) is responsible for incorporating all components of the Plan of Care required per CMS Conditions of Participation, Patient Driven Grouping Model, and for branches within North Carolina, Review Choice Determination.  The member will ensure that documentation meets CMS requirements for medical necessity, homebound, and appropriate visit utilization based on disease processes.  The CCUS is additionally responsible for ensuring that the Face to Face Encounter meets CMS requirements for compliance and is incorporated into the Plan of Care. This role is available as a resource on episodic patient care management to branch leadership and field staff.

 

Our comprehensive benefits include:

• Affordable medical, dental and vision
• Tuition reimbursement and discounts
• Paid time off
• 401(k) retirement savings plan
• Flexible Spending Account (FSA)
• Employee Assistance Program (EAP)
• Employee discounts

• Reviews completed Coding and OASIS using standard utilization review to ensure all corrections and Oasis recommendations have been addressed by the PCM and clinician
• Reviews ICD-10 codes on Oasis to ensure the Focus of Care is aligned with both coding and F2F documents
• Reviews all Goals and Interactions for accuracy and completion
• Communicates any corrections needed to field clinicians prior to completion and follows up to ensure timely response and completion of corrections
• Communicates with PCM/ Case manager/ Clinical Manager or Branch manager of pertinent issues and trends to assure optimal reimbursement per PDGM financial drivers (e.g. HIPPS scores, Case Mix Weight)
• Participates in clinical improvement teams and benchmarking activities as assigned
• Participates in select data collection as requested to track and trend practice patterns, and intervenes to affect change in practice
• Participates in peer review of role accuracy per manager request
• Updates patient care records as outlined in company policies and procedures
• Utilizes appropriate terminology and abbreviations
• Advocates for needed patient services or resources, based on clearly communicated quantifiable information
• Collaborates with Intake, Sales, and other interdepartmental teams as needed to ensure adequate process flow for referral and clinical information as needed to produce a comprehensive Plan of Care for episodic admissions and recertifications
• Serves as a resource and provides support to associated branches support staff to facilitate completion of documentation, process flow, timeliness, and other needs as determined by the branch relating to the Plan of Care/485

Competency, Skills and Abilities:

 

• Home health clinical knowledge
• Experience/knowledge of ICD-10 coding and Oasis documentation (Certification preferred)
• Expert written and verbal communication skills
• Strong interpersonal skills
• Knowledge of the regulatory requirements
• Ability to prioritize tasks and manage multiple projects
• Strong analytical and problem-solving skills with attention to details
• Proficient use of Microsoft Outlook 365 – Excel, Word and PowerPoint, WebEx
• Experience with Wellsky EMR software
• Solid ability to learn new technologies and possess the technical aptitude required to understand flow of data through systems as well as system interaction

 

Education and Experience Requirements:

 

• Two (2) year degree from an accredited or approved school
• Current clinical license for the state of practice
• OASIS certification is preferred
• Three (3) years of related home health clinical experience

Physical Demands and Work Environment:

 

• This position will work from branch locations 50% of the time.
• Must have established primary internet access at home, with back up hot spot or WiFi device in the event of internet interruption.
• Working environment may be stressful at times as overall office activities and work levels fluctuate.
• This position requires typing, bending, stooping, stretching and sitting for extended periods.
• Ability to perform repetitive motions of wrists, hands and/or fingers due to extensive computer use.
• Subject to long periods of sitting and exposure to computer screen.
• Excellent ability to communicate both verbally and in writing.
• Quarterly travel to team meetings required per manager request.
• Ability to utilize a personal computer and other office equipment. Company issued equipment should be utilized and it is the responsibility of the employee to maintain said equipment in good working order.

     

All Saints Hospice promotes the physical, emotional and spiritual well-being of both the person experiencing life's journey and their faith. Our mission is to provide the highest standard of care to our patients and the entire community that surrounds each patient. We strive to holistically meet their spiritual, social and clinical needs in the most peaceful, dignified and comforting manner possible. We are always mindful of the privilege we are granted through our hospice ministry to express compassion, respect, sensitivity, hope and love. For more information about All Saints Hospice, please visit www.allsaintshospice.com. Follow us on Facebook and LinkedIn.