job Title
Home Health Quality Assurance (QA) / Coding Specialist
Department
Clinical Operations
Reports To
Director of Nursing (DON) / Clinical Manager
Position Summary
The Home Health Quality Assurance (QA) / Coding Specialist is responsible for reviewing clinical documentation to ensure compliance with Medicare Conditions of Participation (CoPs), state and federal regulations, and agency policies. This position performs ICD-10 coding, OASIS review, chart audits, and quality assurance activities to support accurate reimbursement, regulatory compliance, and high-quality patient care.
Essential Duties and Responsibilities
Quality Assurance
- Review all patient records for completeness, accuracy, and regulatory compliance before billing.
- Conduct pre-bill and post-bill chart audits to ensure documentation supports skilled services provided.
- Ensure compliance with Medicare, Medi-Cal, CMS, ACHC/JCAHO (if applicable), and agency policies.
- Monitor documentation for timeliness, physician orders, signatures, and required certifications.
- Identify documentation deficiencies and communicate necessary corrections to clinical staff.
- Track quality indicators and assist with agency Quality Assessment and Performance Improvement (QAPI) initiatives.
- Maintain audit logs and quality improvement reports.
Coding Responsibilities
- Assign accurate ICD-10-CM diagnosis codes based on physician documentation and clinical records.
- Review and validate primary and secondary diagnoses to ensure appropriate reimbursement.
- Verify coding accuracy for OASIS assessments and Plans of Care.
- Stay current with ICD-10 coding updates and CMS reimbursement guidelines.
- Collaborate with clinicians to clarify diagnoses and improve documentation specificity.
OASIS Review
- Review Start of Care (SOC), Resumption of Care (ROC), Recertification, Transfer, Discharge, and Follow-Up OASIS assessments.
- Validate OASIS accuracy, consistency, and regulatory compliance.
- Ensure OASIS submissions are completed within CMS-required timeframes.
- Provide education and feedback to clinicians regarding OASIS documentation and scoring.
Compliance & Education
- Monitor agency compliance with Medicare Conditions of Participation.
- Assist in preparing documentation for surveys, audits, and accreditation reviews.
- Provide education and guidance to clinicians regarding documentation standards, coding updates, and regulatory changes.
- Participate in quality improvement meetings and interdisciplinary team discussions.
Documentation Management
- Review physician orders, face-to-face documentation, certifications, recertifications, and plan of care documentation.
- Ensure documentation supports medical necessity and homebound status.
- Verify all required documentation is complete prior to claim submission.
- Maintain confidentiality in accordance with HIPAA regulations.
Qualifications
- Current LVN or RN license preferred but not required, depending on agency needs.
- Certified Home Health Coding Specialist (HCS-D), COS-C, or equivalent certification preferred.
- Minimum of two (2) years of home health experience.
- Minimum of one (1) year of ICD-10 coding and OASIS review experience preferred.
- Thorough knowledge of Medicare Conditions of Participation and home health regulations.
- Strong understanding of ICD-10-CM coding guidelines.
- Experience with electronic medical record (EMR) systems.
- Excellent organizational, analytical, and problem-solving skills.
- Strong written and verbal communication skills.
- Ability to work independently while managing multiple priorities.
Knowledge, Skills, and Abilities
- Knowledge of Medicare reimbursement methodologies (PDGM).
- Proficiency in OASIS-E documentation and CMS regulations.
- Ability to identify documentation deficiencies and recommend corrective actions.
- Strong attention to detail and accuracy.
- Excellent time management and organizational skills.
- Ability to maintain strict confidentiality.
- Proficiency in Microsoft Office applications and EMR software.
Physical Requirements
- Prolonged periods of sitting and computer use.
- Ability to lift up to 20 pounds occasionally.
- Ability to communicate effectively by phone, video conference, and in person.
Work Environment
- Office-based position with the possibility of remote or hybrid work, depending on agency policy.
- Standard business hours with occasional overtime during audit periods or regulatory deadlines.
Performance Expectations
- Maintain high coding accuracy and documentation quality.
- Ensure timely completion of chart reviews and coding assignments.
- Support agency compliance with all Medicare and state regulations.
- Contribute to improved patient outcomes and successful survey results through continuous quality improvement efforts.