Home Health Documentation Review Nurse na Michiana Home Care

POSITION SUMMARY
Our primary focus is the promotion and application of superior documentation on our home health
patients. The Documentation Review Nurse will be responsible for performing comprehensive
documentation reviews. The reviews will focus on assigning accurate ICD-10 codes and accurate OASIS
completion, while maintaining compliance within regulatory requirements. Work may be completed
remotely.
QUALIFICATIONS
• Minimum of five (5) years’ experience in a home health setting, preferred.
• Minimum of 2 years recent Home Health ICD-10 coding and OASIS review experience
• Graduate of an approved educational program for nursing
• Active RN license
• Background in a management, operations, or quality assurance performance improvement role within the
home health industry is a plus
• Extensive knowledge of CMS Home Health, ACHC, and state (if applicable) regulations including OASIS,
coding and Plan of Care requirements.
• OASIS (COS-C or HCS-O) and Coding Certifications (HCS-D) highly preferred
• Experience with the WellSky electronic medical record, a plus
• Excellent written and verbal communication skills
• Proficiency with Microsoft Office preferred
• Strong quantitative and analytic skills
• Ability to adapt to a rapidly changing working environment
ESSENTIAL FUNCTIONS/AREAS OF ACCOUNTABILITY
1. Performs patient record reviews to determine complete, accurate, and timely documentation of all patient
conditions and severity codes that support medical necessity for home health and treatment of the patient.
2. Reviews all OASIS time points using the WellSky and SHP scrubbers to ensure OASIS process and
outcome measures are accurate.
3. Assigns accurate ICD-10 codes for patient diagnoses and queries the clinician, physician, or other allowed
practitioners to obtain missing, unclear, or conflicting documentation.
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4. Recognizes opportunities for documentation improvement using their extensive knowledge and strong
critical-thinking skills. Uses sound judgment in decision- making and keeps reimbursement considerations
in balance with regulatory compliance.
5. Monitors PDGM Score Card Overview Report in SHP to ensure that all potential revenue is realized.
6. Monitors Functional Impairment Status threshold to verify the patient is scored accurately.
7. Develops and/or provides ongoing education and information regarding documentation regulations to
clinicians
8. Participates in weekly managers meetings and reports on current agency trends and metrics.
9. Participates in monthly clinical staff meetings and educates the patient-care team regarding
documentation regulations and guidelines and any negative documentation trends.
10. May assist with training new employees on the home health care documentation principles, which may
include homebound status, medical necessity, skilled intermittent care, physician or allowed practitioner
orders, and accurate OASIS completion.
11. Works collaboratively within all Agency departments (i.e., intake, business development, or administrative
support team), to identify and obtain missing patient documentation.
12. Performs job in compliance with agency policies and procedures, ACHC regulations, CMS regulations,
state regulations (if applicable), and professional standards.
13. Prioritizes daily audits based on chronological age of documents.
14. Communicates any continued negative documentation trends to the Clinical Manager, Clinical Team
Manager, and potentially, Administrator.
15. Maintains weekly productivity threshold of a minimum of 30 chart audits per week.
16. Stays current on knowledge of the home health industry and any upcoming regulatory changes.
17. Executes the responsibilities of a Documentation Review Nurse according to lawful and ethical standards,
as referenced in the Agency’s policies and procedures, Standards of Conduct, and Corporate Compliance
policy.
18. Employee acknowledges that they have a duty to report any suspected violations of law, or of the
Standards of Conduct, to the Legal Compliance Manager or Administrator.
19. Performs other duties, as assigned, that falls within the realm of capabilities of the incumbent.
20. This job description is not designed to cover or contain a comprehensive listing of activities, duties or
responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may
change at any time.