QA-Coding Nurse

Essential Functions:

1. Is capable of performing all the essential functions of a RN/LPN/LVN.
2. Responsible for implementation and monitoring of the Agency's Quality Improvement program.
   
   • Provides direction and coordination of quality improvement activities utilizing Agency's QA policy.
   • Coordinates activities related to medical record review for data collection.
   • Works collaboratively to assure documentation is complete and consistent with care and reflects legal, regulatory and Agency requirements.
3. Participates in the development, implementation, coordination and maintenance of a program designed to identify problems, opportunities for improvement and resolutions that maximize quality of care rendered to home health care patients.
   • Implements monitoring activities in accordance with the approved quality assessment and improvement plans.
   • Accessible to clinicians and Admin Coordinator on the team throughout the day for any problems, questions, needs either by phone, fax, or in person.
   • Participates in the review of documentation prior to being filed and maintained in the client's record for accuracy, skill and consistency.
   • Implements monitoring activities in accordance with the approved Quality Assessment and Improvement Plan.
   • Assists in the identification and implementation of appropriate measures for correction of identified problems or concerns in the delivery of home care services.
   • Performs reassessment activities designed to ensure that identified problems or concerns have been eliminated or reduced to an acceptable level.
   • Develops data collection tools to document quality assessment and improvement activities.
   • Assists in the development of tools to illustrate pertinent data to the Utilization Review/Quality Assessment and Improvement Committee.
   • Prepares and submits written quality summary reports for the Director of Quality Assurance or Compliance Officer.
   • Audits documentation corrections and monitors the return of documented materials that are incomplete and/or not in compliance with Agency standards, policies and procedures.
   • Analyzes charts for compliance and to facilitate billing process as assigned.
   • Protects and maintains the confidentiality of quality assessment and improvement activities.
4. Responsible for ensuring processes to monitor and evaluate safety, risk management and infection control.
   
   • Educates and implements monitoring activities for safety, risk management and infection control.
   • Acts as resource to staff in identifying safety and risk management issues for patients and staff.
   • Reviews incident reports for completeness, risk, standard of care determination and appropriate follow-up. Maintains a log for trending and makes recommendations related to trends identified.
   • Maintains current knowledge related to home care safety and infection control standards and Agency policy.
5. Monitors Agency compliance with state federal guidelines.
   
   • Maintains current knowledge related to Medicare Conditions of Participation and CHAP and other licensing bodies requirements.
   • Participates in quality assurance activities as directed to monitor Agency compliance with regulations and regulatory bodies.
6. Acts as clinical resource to staff.
   
   • Maintains updated nursing knowledge and skills.
   • Assists with staff education as needed.
   • Assist with communicating information regarding changes in Agency operation.
   • Participates in the development and implementation of quality assessment and improvement programs.
   • Ensures clinicians are following best practice skills, documenting accurately, visiting/treating the patient per approved schedule and time and according to POC (plan of care) signed by physician.
7. Participates in professional growth and development.
   
   • Maintains professional and technical knowledge my attending educational workshops, reviewing professional publications, establishing personal and professional networks and participates in professional organizations or societies.
   • Demonstrates current knowledge of quality assessment and improvement, communication and organizational principles.
   • Maintains current professional licensure.
   • Provides input to the development and revision of Agency clinical and administrative policies and procedures.
8. Fulfills additional performance responsibilities as assigned and as necessary.
   • Performs Medical Records responsibilities as assigned and necessary. 

Medical Records Responsibilities for QA (If Applicable):

1. Handles communications efficiently and responsively.
   
   • Monitors and receives/distributes incoming faxes and mail.
   • Responds to Fieldstaff's inquiries related to the patient's clinical record.
   • Mails out/faxes documents requiring the physician's signature.
   • Tracks/monitors unsigned physician orders to ensure signatures are obtained in a timely manner according to Agency policy.
2. Manages all daily medical records accurately.
   
   • Sets up new patient records and files in the department.
   • Files clinical documentation on a regular basis.
   • Performs other file management tasks as requested.
   • Prepares discharged charts for storage.
3. Audits the end episodes following the patient discharge in compliance with Medicare regulations and Agency policies.
   
   • Maintains comprehensive working knowledge of Medicare documentation guidelines per Agency policy.
   • Reviews the documentation maintained in the client's chart in accordance with Agency policy.
   • Identifies compliance issues and present results to appropriate personnel.
   • Assists QA personnel with concurrent review and end episode chart review.
   • Works collaboratively under supervision to assure documentation is complete and consistent with care and reflects legal, regulatory and Agency requirements.
4. Fulfills additional performance responsibilities as assigned and as necessary.