Utilization Review Manager Jobs in Rochester, NY

Full Time

Clerical

Monroe County NY, Rochester, NY, US

Salary Range: $77,000.00 To $92,000.00 Annually

NYS Registered Nurse professional license is require for this opportunity

Role and Responsibilities

The Home Care Quality Assurance (QA) Specialist is responsible for monitoring, evaluating, and improving the quality of care delivered by the home health agency. This role ensures compliance with CMS Conditions of Participation, State regulations, Star Ratings, Value-Based Purchasing (VBP), and internal quality standards. The QA Specialist collaborates with clinical leadership to analyze data, identify performance gaps, provide staff education and drive continuous quality improvement initiatives.

Essential Functions

Quality Monitoring & Auditing

• Conduct routine and targeted audits of clinical records for utilization review to ensure accuracy, completeness, and regulatory compliance

• Review OASIS documentation for clinical accuracy and impact on Star Ratings and VBP measures

• Ensure compliance with CMS, state, and accrediting body requirements

• Identify trends, deficiencies, and opportunities for improvement

• Assist with processing of workflow as requested

• Perform audits and identify trends related to hospitalizations

Education & Staff Support

• Provide feedback and education to clinicians (1:1 or group settings) regarding documentation best practices and quality standards

• Assist with development and delivery of quality-focused education and training programs

• Serve as a resource for staff related to quality measures, compliance, and performance outcomes

• Remain up to date on industry changes and maintain certifications

Collaboration & Communication

• Work closely with clinical leadership, clinical education, operations, and intake staff to improve patient outcomes and ensure clinical documentation is up to date with best practice standards and regulatory requirements

• Communicate quality findings clearly and professionally to interdisciplinary teams

• Participate in quality meetings and performance review discussions

• Other duties as assigned.

This job description reflects management’s assignment of essential functions; and nothing in this herein restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Qualifications and Requirements

Required

• Licensed clinician (RN preferred; PT, OT, or other licensed home health clinician considered)

• Minimum of 2–3 years of home health experience

• Strong knowledge of OASIS, CMS regulations, and home health quality measures

• Experience with clinical documentation review and audits

• Strong analytical, organizational, and communication skills

• Computer literacy and experience with Microsoft Office

• Must have current, valid driver’s license and reliable transportation.

• Attention to detail

• Data-driven decision-making

• Continuous improvement mindset

Preferred

• Quality, compliance, or QAPI experience in home health

• Familiarity with EMR systems (HCHB) and quality reporting tools (SHP)

• Certification in healthcare quality or compliance (e.g., HCS-D, COS-C, or similar)

Work Environment

The Quality Assurance Specialist is primarily in an office setting and may be exposed to outdoor conditions.

The working conditions are classified as sedentary work:

• Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

• Occasional travel to branch offices or field staff meetings is required

Physical Requirements

The following is a description of the physical requirements on a daily basis for the Quality Assurance Specialist. While performing the duties of the job the employee is regularly expected to:

• Stand

• Sit

• Hear

• Walk

• Talk

• Stoop or kneel

• Repetitive motion

This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed as assigned.