Definition:

Remote Clinical Coder and Quality Review for the Home Care division.

Line of Authority:

Director of Coding Education and Compliance, Home Care; Director of Home Care Services

Qualifications:

  • One to Two years of experience in Home care required
  • Certification and formal training and education in ICD-10-CM diagnosis coding required as well as OASIS Certification
  • Licensed Clinician-RN, LPN, PT, PTA, OT, COTA, or ST.

Performance Requirements:

  • Microsoft Excel experience
  • Typing and data entry proficiency
  • Web-based application experience
  • OASIS review and instruction
  • ICD-10-CM introduction and education preferred
  • Lifting and transferring of tools of the trade and travel supplies as needed
  • Able to carry out fine motor skills with manual dexterity
  • Able to sit for extended periods of time
  • Able to see and hear adequately in order to respond to auditory and visual requests
  • Able to speak in clear, concise voice in order to communicate adequately
  • Able to read, write, and follow written orders
  • Must have reliable personal transportation and the ability to travel as needed

Specific Responsibilities:

  1. Responsible for participating in the pre-lock abstraction of relevant medical information for the assignment and sequencing of diagnosis codes by remote review of home health agency records and provided other clinical historical records.
  2. Responsible to assure alerts and omissions of the OASIS are identified and corrected according to policy/procedure.
  3. Accurately interprets and applies Home Care policy and procedure, as well as regulatory rules and guidelines pertaining to diagnosis coding and sequencing.
  4. Accurately assigns, sequences, data enters, diagnoses codes with a minimum of 95% accuracy within the required completion time frame.
  5. Is required to maintain an average daily quota as assigned.
  6. Guides Home Care staff in following Home Care policy and procedure, Official Coding Guidelines and related M items.
  7. Reports any discovered medical diagnoses coding errors or noncompliance with stated policy, rules, guidelines and other NHC coding processes to Director of Coding Education and Compliance or other appropriate Regional or Corporate clinical support staff.
  8. Accurately maintains electronic files and logs of all completed Diagnoses and Coding Forms, as well as accurately maintains original records of all received supporting documentation for the indicated time frame.
  9. Effectively communicates all requests for additional or clarification of information to the appropriate agency.
  10. Seeks opportunities to increase knowledge base and broaden expertise and keeps professional credentials current.
  11. Supports and assists other Home Care Administrative or Regional personnel as needed.
  12. Performs other duties as assigned by Director of Coding Education and Compliance and/or Director of Home Care Services/ Vice President of Home Care.

Definition:

The Registered Nurse (RN) utilizes the nursing process in accordance with physician’s orders to provide patient/family care and support/advocacy in the home setting.

Line of Authority:

Director of Nursing, Administrator/Director of Services; Regional Administrator; Assistant Vice President, HomeCare

Qualifications:

  1. Licensed Registered Nurse in the state where HomeCare agency is located.
  2. Minimum one (1) year experience as a RN/professional nurse.
  3. Experience in home care is desirable.

Performance Requirements:

  1. Ability to read, write, learn, absorb, and apply professional training; follow physician’s orders and keep records in prescribed manner.
  2. Ability to be reaching, bending, squatting and twisting numerous times daily.
  3. Ability to lift 70-80 pounds on occasional basis.
  4. Ability to see and hear adequately in order to respond to auditory and visual requests from patients.
  5. Ability to speak in clear, concise voice in order to communicate adequately.
  6. Ability to carry out fine motor skills with manual dexterity.
  7. Mental acuity high enough to adequately perform job requirements.
  8. Must have reliable personal transportation and be able to drive in inclement weather and variable road conditions.

Specific Responsibilities:

  1. Utilizes the nursing process to identify and achieve patient goals: assessment, planning, implementation, and evaluation.
  2. Assesses the physical, psychosocial, and environmental factors that affect a patient’s health to develop a comprehensive nursing care plan which will attain the patients desired health outcomes in a culturally comfortable way.
  3. Collaborates with the interdisciplinary team to assure personal care, medical care and rehabilitation provide for optimal patient health and well-being.
  4. Teaches patient/caregiver in various aspects of health care and disease management appropriate to needs/level of education and understanding and documents continuing needs and levels of patients/caregivers understanding.
  5. Provides and documents skilled nursing care according to the plan of care/physicians orders, policies/procedures and standards of care.
  6. Provides nursing services within the scope of practice authorized by the license issued by the state for a registered nurse.
  7. Employs strategies to promote health and a safe environment, including implementation of infection control and safety policies.
  8. Evaluates progress toward the attainment of outcomes/goals and modification of plan as needed.
  9. Participates in on-going care coordination and maintains positive relationships with referral sources, physicians/other clinicians, patients/families, and other partners.
  10. Participates with other nurses in taking weekend, night and holiday calls on a rotating basis.
  11. Continually strives to improve nursing care through participation in inservice activities, staff development activities and continuing learning.
  12. Teaches, supports, and supervises Licensed Practical Nurses and Home Health Aides.
  13. Serves on committees as assigned.
  14. Performs other duties as assigned by the DON/Administrator/Director of Services.