JOB PURPOSE:

Under the direction of the SDR Unit Lead, the Quality Review Specialist – RN is responsible for reviewing, triaging, process, and/or investigating, as necessary, all service determination requests received. Will perform a quality review of all data submitted by the IDT teams and PACE Service Coordinators in Care Compass. The role will ensure that service determination requests (SDRs) are handled in a timely and efficient manner and in compliance with the relevant policies & procedures. The role will also perform a variety of duties involving entering, confirming, and updating patient service support documentation. This will include frequent communication with participants and collaboration with various teams within to collect and process participant data effectively.

JOB RESPONSIBILITIES:

• Reviews daily tasks and assigns SDR cases for coordination with IDT and timely resolution.

• Provides all administrative-related information and routes accordingly for proper clinical review.

• Completes SDR assessments and coordination notes into the Care Compass EMR database related to the SDR process, approved services, delivered services, etc.

• Collaborates with the inter-disciplinary team (IDT), CSDs, and care delivery supervisors to ensure service determination requests (SDRs) are completed in a timely manner.

• Works closely with the site-associated Care Delivery department to ensure data is entered correctly and in a timely manner.

• Reviews documentation completeness related to the rationale for all service determination requests (SDRs) IDT decisions.

• Outreaches participants, caregivers, representatives, IDT members, and others to keep them informed about the status or resolution of requests.

• Keeps IDT members updated with SDR process status.

• Coordinates, documents & follows up with staff in different departments issues and/or requests resolutions.

• Completes assigned daily/weekly notification calls for all SDR decisions, including appeal rights information for denials and partial approvals.

• Completes validation calls to participants, caregivers, or representatives to confirm that all approved services were received timely.

• Prepares detailed written responses to all participants/caregivers/representatives regarding the resolution of the service request.

• Responsible for completing, scanning/uploading into EMR all denial letters, including date-stamped mailing envelopes.

• Assists with follow-up and escalation of the SDR step process as necessary.

• Provides general administrative support as needed.

• Monitors daily and weekly pending SDR case reports.

• Maintains departmental quality and productivity goals.

• Adheres to all applicable compliance requirements and the Code of Conduct.

• Only act within the scope of the individual’s authority to practice.

• Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: Bachelor's or Associate degree in Nursing.

Experience:

• Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

• Able to pass typing-test with at least 45 WPM.

• Excellent written and verbal communication skills (grammar, spelling, and punctuation).

• Ability to thrive in a fast-paced environment and meet assigned deadlines.

• Excellent organizational skills, accuracy, and attention to detail.

• Demonstrated ability to manage multiple projects and be flexible.

• Ability to operate both independently and collaboratively as required.

• Proficiency in Microsoft Office suite, including Word, Excel and Outlook.

Additional Requirements:

• Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.

• Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.

• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.

• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc.

• Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc.

• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day.

• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)

• Sight/Visual Requirements – Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy.

• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.

• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

Salary Range (Min-Max):$100,000.00 - $110,000.00