HH Clinical Record Auditor

BrightSpring Health Services

The Clinical Record Auditor is a clinician that conducts a comprehensive assessment of home health clinical records to ensure clinical documentation requirements are met, that it is clear, reflects the care provided, the patient's response to care, meets regulatory and company requirements, reflects patient eligibility, and supports billing requirements. Informs local operations leadership, and the clinical support team of results to facilitate performance improvement. Identifies and informs upline management and clinical support team of trends and makes recommendations for corrective action.

Performs clinical record reviews to ensure compliance with coverage requirements, physician's orders, care delivery standards, company policy, regulatory requirements, and accreditation standards.
• Keeps abreast of all company policies/procedures; local/state/federal laws/regulations and accreditation standards.
• Remains current with ICD-10 Coding changes OASIS guidelines, CMS changes and other agency directives.
• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
• Examines documentation to ensure clinical information is complete and accurate.
• Review's information contained in records to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or Medicaid payment policies.
• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means.
• Identifies issues requiring clarification or additional information in the clinical documentation and informs Quality/QAPI team for communication with the appropriate care provider using the established processes.
• Always maintains medical records confidentiality through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Collaborates with local leadership and the clinical support team in educating local leadership and clinicians to improve documentation for quality reporting based on trends identified during record reviews.
• Identifies trends and opportunities for performance improvement and works proactively to find solutions.
• Assist Compliance and/or Quality Team with any chart reviews as requested by state or federal agencies or from payers as well as internal targeted investigations/reviews.
• Provide support to ensure that clinical information and quality data utilized in profiling and reporting is complete and accurate.
• Maintains an open and collaborative working relationship with the patient care team and clinical support team.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following policies, procedures, and guidelines.
• Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy. Average six-to-eight-episode reviews per day.
• Accurate and timely submission of all administrative and review related documents to appropriate parties.
• Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
• Communicates with Corporate Compliance department any reportable findings or issues identified during the location assessment that would potentially put the Company at risk.
• Communicates assessment findings to location leadership and upline management and provides expertise regarding policy interpretation, process improvement and follow-up actions required.
• Identifies and communicates recommendations for revisions or modifications of company policies, practices and processes as indicated.

• Active unrestricted RN license
• Associate degree in Nursing or the equivalent
• Minimum eight years of clinical experience in a Home Health or Home Care setting required, including a minimum of two years' experience in homecare clinical management and/or operations
• Must exercise independent judgment, critical thinking, ability to work independently while following CMS guidelines, organizational policies, and procedures
• Knowledge of current Home Health regulations and operations
• Medical record abstracting skills required
• Knowledge of the organization of medical records, medical terminology, and disease process required
• Strong clinical assessment and critical thinking skills required
• Excellent verbal and written communication skills required
• Ability to work independently and meet targeted review numbers
• Flexibility and strong organizational skills needed
• Proficiency in computer applications including Microsoft Word and Excel programs. Must be proficient in navigating electronic medical records

Must be proficient in navigating Home Care Home Base.