Job Summary:

Responsible for auditing, organizing, assembling, summarizing and submitting medical records.

Essential Functions:

• Audits medical records and records findings on an approved audit tool.

• Request documents to fill medical record/ADR request as needed.

• Gather, organize, and assemble medical records for submission per request.

• Compose Clinical Summaries and/or Physician letters that describe patients’ course of care and point surveyors to specific eligibility criteria per Local Coverage Determination guidelines.

• Ensure final medical record packets include all requested documents including updated documents that were requested post audit.

• Submit medical records as requested via mail, fax, on-line portal etc.

• Participate in preparations for hearings including but not limited composing hearing notes that will assist those who testify.

• Willingness to ask questions and seek knowledge required to complete assigned tasks.

• Take necessary precautions to protect personal health information related to the above duties and responsibilities.

• Maintains knowledge base in specialty by participating in CMS/MAC, electronic medical record system, vendor specific training opportunities and others as directed.

• Collaborates with clinical team members and leaders at all sites in relation to the medical record as needed.

Additional Responsibilities:

• Performs other duties as assigned or requested.

• Conforms to all applicable Agency policies and procedures.

• Participates actively in continuing education and in-services.

• Maintains confidentiality of patient information and business trade practices

Knowledge / Skills / Abilities:

• Organizational skills

• Proficient use of Word, Adobe, PowerPoint, Excel, Jira

• Time management

• Cooperative attitude

• Ability to work flexible schedule and/or evening hours, as needed

• Advanced written and verbal interpersonal communication

• Ability to multi-task, work under pressure with changing priorities and short deadlines, and effectively handle a heavy workload.

• Ability to adapt to and use multiple software platforms as needed.

• Ability to engage in local and overnight travel to alternate offices throughout the US as needed.

• Knowledge of Home Health and Hospice Conditions of Participation, with focus on regulations related to technical components of the medical record

• Knowledge of State Home Health and Hospice Regulation, with focus on regulations related to technical components of the medical record.

• Knowledge of Local Coverage Determination for Home Health and Hospice.

Information Management:

Treats all information and data within the scope of the position with appropriate confidentiality and security.

Risk Management:

• Cooperates fully in all risk management activities and investigations.

• Keeps abreast of changes in health care law.

Minimum Position Qualifications:

• Education:

Graduate of an accredited School of Nursing for LVN or LPN

• Experience:

3-5 years in home health or hospice, preferred

3-5 years HomeCare, HomeBase, preferred

• License / Certification:

Current State LVN / LPN license; current driver’s license and proof of auto liability

Environmental Conditions:

Works under a variety of conditions in facilities and offices; ability to work flexible schedule, ability to travel frequently to other offices with overnight stays. Moderate noise level; moderate stress and emotional demands.

Physical Requirements: Sitting is required. Requires ability to always handle stressful situations in a calm and courteous manner. Requires working under some stressful conditions to meet deadlines and agency needs.