Utilization Review Specialist - VNA

DEFINITION/PRIMARY FUNCTIONS

The Utilization Program Specialist is responsible for evaluating the necessity and appropriateness of services to ensure that they are effective and cost efficient. The Utilization Program Specialist works in tandem with the Clinical Manager to assist the clinical staff with case management and ensure care is delivered according to BVNA standards/pathways and regulatory requirements. He/she provides direction and acts as a resource for Clinical Managers and staff regarding reimbursement. The Utilization Program Specialist organizes, complies and translates medical information into medical codes according to home care coding conventions.

POSITION QUALIFICATIONS

(Minimum qualifications are required unless stated otherwise.)

Experience:

Minimum of 3 years of work experience in a certified home health agency. Experience with quality assurance or utilization review preferred. Knowledge of current regulations governing third party reimbursement for home health required. Ability to cooperate, guide and instruct a multi-disciplinary team required. Ability to exercise independent judgement; demonstrated time management skills; demonstrated ability to facilitate smooth flow of home care patients. Demonstrated ability to conform with Service Excellence Standards Demonstrated knowledge of Conditions of Participation in home care. Demonstrated general computer skills required. Demonstrated knowledge of Windows, including Microsoft Word, Excel and E-mail preferred.

Education and Training:

BSN nursing strongly preferred. Certification in Current version of Home Health coding required.

License, Certification & Registration:

RN

• Currently licensed as an RN in the state of Massachusetts OACSHC
• Certification in Outcome and Assessment Information Set (OASIS) as a COS-C
• OASIS Specialist-Clinical or HCS-O
• Home Care Clinical Specialist. DRIVER

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Driver's License Other Requirements:

Ability to maintain confidentiality. Ability to be flexible regarding work hours. Knowledge of community resources. Demonstrated problem-solving ability.