Home Health Documentation Review Nurse (On-Site)

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

• 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.

• Reviews all OASIS time points using the WellSky and SHP scrubbers to ensure OASIS process and
  
  
  

outcome measures are accurate.

• Assigns accurate ICD-10 codes for patient diagnoses and queries the clinician, physician, or other allowed
  
  
  

practitioners to obtain missing, unclear, or conflicting documentation.

2024 Michiana Home Care. All Rights Reserved. Page 141 of 216 423 Sycamore Street, Suite 104, Niles, MI 49120-2374

P^0P Manual - Personnel.docx (269) 687-2900 (888) 687-2904 (269) 687-2903 Fax

Michiana Home Care C-245

• 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.

• Monitors PDGM Score Card Overview Report in SHP to ensure that all potential revenue is realized.
• Monitors Functional Impairment Status threshold to verify the patient is scored accurately.
• Develops and/or provides ongoing education and information regarding documentation regulations to
  
  
  

clinicians

• Participates in weekly managers meetings and reports on current agency trends and metrics.
• Participates in monthly clinical staff meetings and educates the patient-care team regarding
  
  
  

documentation regulations and guidelines and any negative documentation trends.

• 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.

• Works collaboratively within all Agency departments (i.e., intake, business development, or administrative
  
  
  

support team), to identify and obtain missing patient documentation.

• Performs job in compliance with agency policies and procedures, ACHC regulations, CMS regulations,
  
  
  

state regulations (if applicable), and professional standards.

• Prioritizes daily audits based on chronological age of documents.
• Communicates any continued negative documentation trends to the Clinical Manager, Clinical Team
  
  
  

Manager, and potentially, Administrator.

• Maintains weekly productivity threshold of a minimum of 30 chart audits per week.
• Stays current on knowledge of the home health industry and any upcoming regulatory changes.
• 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.

• 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.

• Performs other duties, as assigned, that falls within the realm of capabilities of the incumbent.
• 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.

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

• 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.

• Reviews all OASIS time points using the WellSky and SHP scrubbers to ensure OASIS process and
  
  
  

outcome measures are accurate.

• Assigns accurate ICD-10 codes for patient diagnoses and queries the clinician, physician, or other allowed
  
  
  

practitioners to obtain missing, unclear, or conflicting documentation.

©2024 Michiana Home Care. All Rights Reserved. Page 141 of 216 423 Sycamore Street, Suite 104, Niles, MI 49120-2374

P^0P Manual - Personnel.docx (269) 687-2900 ▪ (888) 687-2904 ▪ (269) 687-2903 Fax

Michiana Home Care C-245

• 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.

• Monitors PDGM Score Card Overview Report in SHP to ensure that all potential revenue is realized.
• Monitors Functional Impairment Status threshold to verify the patient is scored accurately.
• Develops and/or provides ongoing education and information regarding documentation regulations to
  
  
  

clinicians

• Participates in weekly managers meetings and reports on current agency trends and metrics.
• Participates in monthly clinical staff meetings and educates the patient-care team regarding
  
  
  

documentation regulations and guidelines and any negative documentation trends.

• 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.

• Works collaboratively within all Agency departments (i.e., intake, business development, or administrative
  
  
  

support team), to identify and obtain missing patient documentation.

• Performs job in compliance with agency policies and procedures, ACHC regulations, CMS regulations,
  
  
  

state regulations (if applicable), and professional standards.

• Prioritizes daily audits based on chronological age of documents.
• Communicates any continued negative documentation trends to the Clinical Manager, Clinical Team
  
  
  

Manager, and potentially, Administrator.

• Maintains weekly productivity threshold of a minimum of 30 chart audits per week.
• Stays current on knowledge of the home health industry and any upcoming regulatory changes.
• 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.

• 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.

• Performs other duties, as assigned, that falls within the realm of capabilities of the incumbent.
• 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.