Provides a wide variety of support services to BBAHC including identifying, planning, and executing improvement projects. Coordinates and conducts daily reviews of Inpatient and Swing bed admissions and other health care services to maximize quality and cost efficiency. Ensures documentation and practice supports admissions and subsequent billing, medical necessity, quality of care, appropriateness of decision-making, place of service, and length of stay. Maintains records to support utilization review decisions. Ensures caregivers understand and meet all documentation requirements. Recognize errors as they occur and take positive steps to resolve those errors.
College Degree required.
Must possess knowledge of specific laws and regulations imposed on healthcare systems by various agencies.
RN, with equivalent quality improvement training required. Prefer BSN Certified Professional in Healthcare Quality.
Must have four years’ hospital experience, with at least one year in corporate compliance, performance improvement, or risk management.
Knowledge of analysis of data to identify patterns and trends is necessary. This includes ability to abstract, compile, and interpret Government Performance Results Act (GPRA) data.
Able to support and enhance Performance Improvement efforts through the use of quality improvement tools, statistics, and data analysis.
Able to facilitate teams crossing multiple departments and functions.
Communications skills, both written and oral, with a functional knowledge of medical terminology required.
Must exercise discretion and maintain confidentiality as governed by HIPAA and HITECH.
Prior IHS /PHS or Federal hospital experience and/or rural hospital experience is desirable.
Knowledge of The Joint Commission Critical Access Hospital standards is required.
Serves as the organization’s GPRA Coordinator.
Maintains awareness of laws, standards and regulations affecting healthcare through education and peer contact.
Develops and implements system-wide Performance Improvement programs, policies and procedures to ensure compliance with applicable federal and state laws and agency regulations.
Directs all aspects of BBAHC’s Performance Improvement program including planning, designing and/or evaluating the principal program.
Provides guidance to key individuals relative to their responsibilities for Performance Improvement.
Builds and facilitates Performance Improvement teams. Assists team leads in developing and managing improvement projects.
Tracks Performance Improvement and Risk Management activities.
Conducts periodic analysis of comments received and events reported to identify emerging trends and recommends process changes to eliminate identified problem areas.
Supports managers in hypothesis and data-driven problem solving.
Reports and explains Performance Improvement projects to internal and external audiences.
Serves as a resource for all BBAHC Performance Improvement review processes, responds to recommendations or deficiencies, and monitors corrective actions for identified recommendations or deficiencies.
Assesses effectiveness of actions taken to implement recommendations or correct deficiencies.
Arranges and facilitates Performance Improvement team meetings when necessary to address complex issues.
In conjunction with the Chief Compliance Officer (CCO), other members of the healthcare team, and available resources facilitates: continuing improvement in the assessment and evaluation of the quality of patient care, formulation of plans to address assessed needs and issues, implementation of improvement plans, evaluation of the effectiveness of plans in meeting established care goals, and revisions of plans as needed to reflect changing needs, issues and goals.
Provides resources, education, and current material to all employees regarding Performance Improvement.
Educates others in the use of appropriate data collection and analysis methods to identify patterns and trends. Assists CCO in developing strategies to: prevent, reduce, and respond to Quality of Care issues; identify process-oriented problems; improve continuity of care; and strive for positive outcomes.
Completes specific Performance Improvement and Risk Management projects delegated directly by the CCO in a timely manner.
Maintains awareness of laws, standards and regulations that may affect healthcare through education and peer contact. Follow strict protocols to determine whether patients meet standards for insurance reimbursement. Uses specific guidance to evaluate process such as Qualis Health’s InterQual criteria.
Advise on questions of hospital admissions, length of stay, imaging studies.
Timely reviews all Inpatient and Swing Bed admissions ensuring documentation supports the admissions.
Work closely with physicians, nurses, health care providers, family members, and insurance companies to ensure appropriate care is provided.
Coordinate with State, Federal, and Third Party payors to resolve denials, understand denial basis, and improve activities to prevent future denials.
Reports patterns of inappropriate documentation to avoid charges of knowingly falsifying documentation and billing. Conducts training with caregivers when patterns documentation problems are noted.
Assists in rapid identification and resolution of documentation and billing problems to reduce delays in the delivery of appropriate patient services and subsequent billing and collections
Develops and implements system-wide programs, policies and procedures to ensure compliance with applicable federal and state laws and agency regulations.
Develops and maintains a utilization review program that promotes effective cost recovery, quality of care and/or compliance with relevant federal and state laws, regulations and standards.
Evaluates follow up and monitors as necessary to ensure implementation of required changes. Assesses effectiveness of actions taken to implement recommendations or correct deficiencies.
Arranges and facilitates utilization review team meetings when necessary to address complex issues.
Educates providers in the use of appropriate documentation and associated rules and regulations. Assists COO in developing strategies to prevent, reduce, and respond to utilization issues; identify process-oriented problems; improve continuity of care; and strive for positive outcomes.
Completes specific utilization review projects delegated directly by the COO, in a timely manner.
Other duties as assigned.