Quality Improvement/CDI Specialist/Case Mgmt.

FUNCTIONS OF POSITION:

Quality Improvement Analyst

1. Performs admission, concurrent, and focused reviews using severity of illness/intensity of service criteria to ensure Q.I./ R.M./ U.R. activities
2. Collects and analyzes data to ensure that quality and cost effectiveness issues are addressed for enhancement of patient care and Q.I./R.M./U.R. activities
3. Maintains daily and monthly work log and/or abstracts on all reviews to ensure effectiveness of Q.I./R.M. activities.
4. Performs Q.I. studies using criteria developed by physicians and other health professionals to enhance and improve patient care.
5. Collaborates with physicians, nurses, and other health care professionals to enhance and improve patient care.
6. Prepares reports, graphs, and statistical data for reporting through committee structure.
7. Communicates with insurance companies and other third-party organizations to ensure appropriate utilization of resources.

CDI Specialist

1. Identify opportunities to impact risk adjustment factors through documentation of complicating and comorbid, or major complicating and comorbid conditions and formulate a provider query based on query guidelines.
2. Complete provider clarification queries per guidelines for instances in which documentation in the medical record is ambiguous, incomplete, or conflicting, and provide timely provider follow-up as needed.
3. Facilitate communication and collaboration among coders, providers, and nurses to identify documentation opportunities that appropriately reflect severity of illness and risk of mortality.
4. Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents.
5. Ensure all clinical documents are in compliance with federal laws in terms of composition.
6. Prepares written reports for internal monitoring and complies data for reporting.
7. Takes continuing education courses and stays up-to-date on changes in laws governing clinical documentation.

Case Manager

1. Prescribes, delegates, and coordinates and evaluates continuing care needs for patient utilizing the nursing process.

2. Participates in Quality Improvement process.

3. Leads and facilities discharge planning at the unit level.

4. Utilizes assessment skills to identify biophysical, psychosocial, environmental, self-care, discharge planning, spiritual and educational needs of patient, family, and /or significant other.

5. Serves as a resource for discharge assessment, re-assessment, discharge planning and patient education; assist nursing staff with education and treatment of patients with special needs.

6. Possess knowledge and clinical skills for post hospital care resources, services, and patient education.

7. Performs admission, concurrent and focused reviews using severity of illness/intensity of service criteria to ensure effective utilization management, including case review for third party pay requirements.

8. Collects and analyzes data to ensure that quality and cost effectiveness issues are addressed for enhancement of patient care and Q.I./R.M./U.R. activities and reports information as needed through hospital committee structures.

QUALIFICATIONS:

EDUCATION: Graduate of approved school of nursing,

EXPERIENCE: Minimum three (3) years clinical experience in related field.

CREDENTIALS: R.N., Bachelor’s Degree Preferred

LICENSE: Current license with State of Missouri

SPECIAL:

PATIENT CONTACT: Personal or verbal contact with patients and families.

Rotating call on weekends

PHYSICAL:

STANDING: Minimal periods, but must be able to sit for long periods of time for reviewing of charts.

WALKING: Must be able to walk quickly to all areas of the hospital and occasionally to a physician office.

LIFTING: Minimal light loads (no more than 15 lbs)

VISUAL: Must have good acuity to review medical records, occurrence forms, computer screens, and

Other tools used in job performance.

HEARING: Audio reception essential for effective understanding and communication with hospital staff

And outside agencies.

SPEAKING: Must have the ability to orally speak for effective communication with hospital staff and outside agencies.