Job Summary:

The Quality Assurance Supervisor (QA Supervisor) position supports the Director of Quality Assurance (Director of QA) in all departmental functions to include supervising the medical records department. This position will assist in ensuring that documentation of the actual care provided to patients is timely, complete and accurate. The QA Supervisor will also be familiar with the Federal and State guidelines/regulations and Lorian’s own policies/procedures in that all patient records admitted to the agency are accurate, complete and up to date.

Qualifications:

• Graduate of an approved school of practical/vocational nursing.
• CA Certified/licensed and in good standing.
• Current ICD-9 Coding Certification or the ability to obtain certification within 1 year from hire.
• Good computer skills to include Microsoft applications (i.e. Word/Excel) and ability to type at least 40 wpm.
• Ability to develop and maintain filing systems, while ensuring an efficient flow of clinical documentation.
• Ability to maintain confidentiality of records and information.
• Ability to be flexible, follow verbal and written instruction while working in a team oriented environment.
• Knowledge of and ability to follow appropriate skilled documentation under Medicare guidelines and conditions of participation.
• Communicates effectively with the clinical and office staff involved in any given case in a constructive, goal directed, and professional manner.
• Knowledge of insurance reimbursement procedure.

Responsibilities:

Quality Assurance :

• Process all Oasis data and application of ICD-9 CM and V diagnosis coding according to federal/ state regulations and Lorian policies/ procedures.
• Inputs all Oasis documentation submitted by the clinical staff to include Admissions, Discharges, Transfers, and Resumption of Care notes. Submits completed information to appropriate Clinical Manager for review and locking.
• Make necessary calls to clinicians of needed corrections to either the 485 or Oasis documentation as needed before submitted to Clinical Manager for review and locking.
• Ascertain that the patients are being referred to other disciplines when needed.
• Reviews Oasis Validation Report with Director of QA when appropriate.
• Report all inconsistencies and Adverse Events immediately to the Director of QA.
• Process data information and generate the Plan of Care (485) with accuracy of all medications, and submit the completed product to a Clinical Manager for review prior to Physician submission.
• Provide individual educational sessions with clinical staff on corrections needed to submitted Oasis documentation on an ongoing basis.
• Report ongoing corrections needed to Director of QA for additional education needs.
• Participate in aggregating data reportable to the Director of QA.
• Provide ongoing training to clinical staff and new hires of Oasis documentation.

Medical Records :

• Directly oversees the Medical Records Departmental functions and reporting changes, issues, problems to Director of QA when needed.
• Ensures that medical records for all patients are accurate, complete, and maintained up to date.
• Ensures all documents are filed in 7 days.
• Ensuring that all medical records are accounted for at all times. Keep track of the sign-out Log for all charts check out from the department by clinical staff within the agency.
• Process all purged charts from the department per agency policy/ procedure.
• Coordinates which charts needs to be purged with the department team and which ones need to be moved to the approved stored area.
• Maintain the agency’s On-Call book with up to the date plan of care (485) documentation at least weekly prior to the start of the upcoming weekend.
• May perform other duties as assigned.