Cigna Utilization Review Remote Jobs in Kentucky

Company:

At Mercy Health Home Care we provide a continuum of integrated home-based services, including home health, hospice, home infusion, palliative, and personal care. Over 10,500 teammates and more than 300 access points nationwide provide high-quality care and manage patients' advanced illnesses in partnership with health systems and long-term care partners. The Compassus Care for Who I Am culture reflects its unique care delivery model, which focuses on each person as an individual as well as a patient, to improve their quality of life in a meaningful way. Learn more at compassus.com.

Reporting to the Home Health Clinical Quality Supervisor. The Clinical Quality Specialist is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders.

The Clinical Quality Specialist performs centralized review of home health comprehensive assessments, plans of care and associated clinical documentation. S/he verifies that OASIS responses, the plan of care and supporting documentation are accurate, internally consistent and compliant with CMS OASIS guidance, the Medicare Conditions of Participation, accreditation standards and organizational policy, and resolves identified discrepancies in partnership with the assessing clinician and agency clinical leadership.

Clinical Review and Documentation Integrity

• Completes assigned review of Start of Care, Resumption of Care, Recertification, Significant Change in Condition and Discharge assessments, plans of care and associated workflows.
• Verifies that OASIS responses are supported by the clinical record and consistent with current CMS OASIS guidance and item conventions.
• Reviews the plan of care for ordered disciplines and frequencies, documented medical necessity, physician information, medication review, homebound documentation and correspondence with the face-to-face encounter record.
• Queries the assessing clinician when documentation does not support a response and completes final review and lock of the assessment following resolution.
• Completes utilization review activities including visit utilization, LUPA risk, recertification appropriateness and hospitalization risk, and documents recommendations for agency action.

Regulatory Compliance

• Maintains working knowledge of the Conditions of Participation, CMS OASIS guidance, accreditation standards, applicable state requirements and billing requirements for assigned agencies.
• Ensures assessments are completed, corrected and submitted within required CMS timeframes.
• Escalates suspected compliance concerns, patterns of documentation deficiency and potential patient safety issues through the established chain of command.

Performance and Continuous Improvement

• Meets established productivity, accuracy and turnaround standards for assigned review work.
• Participates in inter-rater reliability review and accepts audit of own review work.
• Provides feedback and education to field clinicians on accurate completion of assessment and plan of
• care documentation and identifies documentation trends that inform process improvement.
• Collaboration and Service
• Partners with agency clinical leadership, field clinicians, coding partners and support teams to resolve review findings.
• Works effectively in a remote team environment and participates in team meetings, learning opportunities and other educational activities as assigned.
• Treats all contacts with respect, supports activities that foster customer service and caregiver satisfaction, and communicates patient care and service issues through the organizational chain of command.

Technology and Professional Development

Uses the electronic medical record, the clinical quality review platform and associated analytics tools proficiently, and adopts new tools and workflows as introduced.

Maintains required licensure, certification and education, and completes orientation, in-service programs and annual competency requirements.

Achieves and maintains proficiency in review across all assessment types, including Discharge OASIS review, and applies current OASIS guidance to review work.

Performs other duties as assigned.

Reviews individual patient records across an assigned portfolio of agencies and states as directed by the Clinical Quality Supervisor.

Agency-level responsibility for the comprehensive assessment, the plan of care and compliance with the Conditions of Participation remains with the agency and its clinical leadership. This role performs centralized review, verification and support.

Corrects and finalizes the comprehensive assessment in accordance with the agency OASIS correction policy.

Documentation accuracy is the objective of this role. Quality measure, star rating and value-based purchasing performance are outcomes of accurate assessment and documentation, and are never pursued through assessment or coding optimization.

Education

• Required: Associate degree or higher

• Preferred: Bachelor's degree

Experience

• Required: Two (2) years of clinical practice experience, including one (1) year in home health

• Preferred: Prior OASIS review, clinical documentation or home health quality assurance experience. Prior experience with electronic medical records preferred
• RN License Preferred

License, Certification and Registrations.

• Active and unencumbered licensure as a Registered Nurse required for review of episodes that include skilled nursing services. Active and unencumbered licensure as a PT, OT or SLP may be accepted for team members whose assigned review is limited to therapy-only episodes.
• Licensure in the state of residence and licensure or applicable compact privilege in each state served, as required by the states within the assigned portfolio. The current state requirement list is maintained by the Clinical Quality function.
• COS-C or HCS-O certification required at time of hire or within one hundred eighty (180) days of hire for external hires, and within twelve (12) months for team members transitioning from an existing Compassus role.

Physical Demands

• Prolonged periods of sitting, standing, and walking while working at a computer conducting meetings, or performing administrative duties.
• Occasional lifting, carrying, pushing, or pulling of up to20 pounds, including luggage, presentation materials, and office equipment.
• Ability to navigate healthcare environments, including patient care settings, offices, and community locations, which may involve stair climbing, bending, reaching, and extended periods of walking.
• Visual acuity sufficient for reviewing reports, analyzing data, and operating standard office technology.

Communication

• Effective communication skills in person, by telephone, and through virtual meeting platforms.

We offer a highly competitive compensation package with an attractive base salary, short- and long-term incentive programs, and competitive benefits. We are committed to building a diverse, inclusive, and equitable workplace where every team member feels valued and empowered to contribute their best. We welcome candidates of all backgrounds, identities, and experiences, believing that our differences make us stronger. Together, we're shaping the future of healthcare with compassion, integrity, and opportunity for all.

Build a Rewarding Career with Compassus
At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others.

Your Career Journey Matters
We're dedicated to helping you grow and succeed. Whether you're pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.

The Compassus Advantage
Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
Career Development: Access leadership pathways, mentorship, and personalized professional development.
Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

Ready to Join?
At Compassus, your career is more than a job-it's an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive.