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Compassus · 2 days ago

Clinical Quality Specialist

Brentwood, TN

Full-time

Onsite

Entry Level

1+ years exp

Compassus is a healthcare organization dedicated to providing compassionate care and support to patients and their families. The Clinical Quality Specialist is responsible for ensuring compliance with OASIS and Medicare regulations, conducting chart reviews, and collaborating with various teams to maintain high-quality patient care.

Elder CareHealth CareTherapeutics

Responsibilities

Completes or reviews all client medical records regarding OASIS

Executes all OASIS reviews on a timely basis

Assures compliance with OASIS time frames as required by law

Completes OASIS activities as appropriate in conjunction with field staff

Reviews and processes the Home Health Director of Clinical Services workflow as assigned, including tasks related to start and resumption of episode, OASIS review and utilization

Performs other duties as assigned

Conduct comprehensive chart reviews for Medicare patients requiring Pre-Claim Review to ensure full compliance with CMS regulations, Medicare coverage criteria, Home Health Conditions of Participation (CoPs), and Compassus policies

Validate that all eligibility requirements are met, including accurate payer verification, homebound status, skilled need, and documentation supporting medical necessity

Review and confirm compliant Face-to-Face (F2F) documentation ensuring encounter timing, provider type, and narrative content align with CMS requirements for home health certification

Examine OASIS assessments, Plan of Care (POC/485), visit notes, and supporting clinical documents to ensure internal consistency and alignment with the patient’s condition, skilled needs, and ordered services

Ensure all orders, frequencies, and durations are appropriate, medically necessary, and clearly supported by physician documentation and clinical narratives

Identify documentation gaps, inconsistencies, or compliance risks and communicate required corrections or clarifications to clinicians, intake, medical records, or leadership in a professional and solution-focused manner

Prepare complete, accurate PCR submission packets including F2F, OASIS, POC, and initial visit notes, ensuring all elements are legible, properly signed, and formatted per MAC requirements

Submit PCR requests through the applicable Medicare Administrative Contractor (MAC) portal (e.g., Palmetto, CGS), ensuring accuracy in NPI selection, episode type, billing codes, and documentation attachments

Monitor the status of PCR submissions and respond promptly to Additional Documentation Requests (ADRs) or reviewer inquiries, gathering and submitting supplemental documentation within required timeframes

Track, trend, and accurately record PCR outcomes, including affirmation status, denial reason codes, turnaround times, and documentation deficiency patterns

Collaborate with clinical, intake, billing, and quality/compliance teams to resolve issues related to documentation, eligibility, or submission accuracy

Participate in quality improvement efforts by identifying process gaps, recommending solutions, and contributing to the development of training materials, job aids, and workflow enhancements

Maintain a high level of accuracy and attention to detail while working in a fast-paced, deadline-driven environment with frequent regulatory updates

Qualification

OASIS compliancePre-Claim Review (PCR)Registered Nurse licenseHome health care experienceCOS-C certificationMathematical skillsLanguage skillsCommunication skills