The Quality Assurance Specialist is responsible for obtaining and maintaining accurate information for each home medical equipment referral/order received based on the payers’ guidelines and specified criteria.  The Quality Assurance Specialist will ensure compliance is maintained for cpap, oxygen, oxygen recertifications, prior authorizations, etc... The Quality Assurance Specialist will utilize the information listed in the Medicare Supplier Manual, the Local Coverage of Determination, the Articles and the Program Integrity Manual to determine the appropriate data to be collected and to insure that all coverage and billing criteria is met. 

Major responsibilities include confirming orders to bill that have accurate documentation.  Correcting and verifying billing issues causing orders to be stopped or put on hold is a daily task for the Quality Assurance Specialist.  The Quality Assurance Specialist will research payment denials, create deposits for remits and request additional documentation that may affect the order from billing out correctly.  Validating compliance for Equipment Maintenance and Insurance Audits are what the Quality Assurance Specialist will ensure.  Obtaining and time stamping physician orders to show required medical documentation needed is demonstrated to show medical necessity on orders.  The Quality Assurance Specialist will work well with staff and assist in training intake specialist as needed. 

1. Ensures compliance is maintained for pap, oxygen orders and oxygen recertifications.
2. Researches and responds to denials, remits, and insurance audits.
3. Responsible for payroll deductions posted on patient accounts. 
4. Correcting issues causing orders to be stopped or put on hold.
5. Preparing and/or confirming orders to bill that have accurate required documentation. 
6. Scanning documentation into the patients Brightree account.
7. Working larger equipment orders to assist the intake specialist on orders.
8. Helps to train and assist staff on all equipment DME orders.
9. Meets with patients to review HME needs.
10. Reviews and monitors all home medical equipment referrals.
11. Reviews the Local Determinations of Coverage via the CGS Website to insure all items are issued to patients in accordance with the established guidelines.
12. Insures that all medical documentation that is required to establish medical necessity or to meet payer criteria is printed and readily available in the patient’s medical record prior to billing and that the data covers the time period leading up to the request of the medical equipment.
13. Insures that all medical documentation is appropriately signed, dated and authenticated. Initiates the appropriate attestation paperwork if information is not signed and dated according to the Program Integrity Manual.
14. Performs data entry of patient information into the HME software
15. Performs verification of the patient’s health insurance coverage for the requested items
16. Completes the insurance verification form accurately and discusses with patient prior to delivery.
17. Monitors all physician orders insuring that the orders are timely, properly signed and dated as required by the Supplier Manual.
18. Contacts patients at specific intervals to assess usage of supplies and equipment. Offers suggestions as appropriate to patient’s comments and responses.  Properly documents all contact.
19. Responsible for maintaining equipment guarantees/warranties.
20. Updates Director on inventory count weekly for equipment and supply needs.
21. Organizes data for patient satisfaction survey results monthly and year-to-date.
22. Verifies insurance, interprets coverage and calculates amount due by patient.
23. Processes claims and generates bills for equipment issued to patients. Insuring that all monies owed are collected.
24. Delivers/picks-up equipment and supplies to patients’ home, at DCH Home Medical Equipment or at the hospital.
25. Provides education regarding the proper use and maintenance of the equipment and uses manufacturers’ service manuals and patient education documentation.
26. Performs functional tests prior to set-up and delivery of the equipment.
27. Provides troubleshooting techniques to patients on equipment.
28. Cleans equipment and insures that maintenance is completed and updated in the HME software system.
29. Responsible for managing equipment repairs back to the manufacturer which involves gathering return authorization and packaging.
30. Responds to patient calls and routes them appropriately, according to degree of urgency.
31. Performs data entry of patient information into the HME software
32. Performs verification of the patient’s health insurance coverage for the requested items
33. Generates and tracks all Certificates of Medical Necessity (CMN) insuring timely signature by the Physician, as required, according to guidelines. 
34. Initiates and completes Advance Beneficiary Notices when appropriate.
35. Updates Director on problems and process improvement in regards to referrals and billing
36. Assists in the coordination of deliveries, insuring that the patient receives the equipment as promised. 
37. Works well with the team on phone calls and walk-ins and patient equipment needs.
38. Rotates in departmental on-call coverage.

      DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

High School Diploma or GED degree required. CPAP and/or respiratory experience preferred. 20 wpm typing required. Must be proficient in the use of Microsoft Office, including Excel and Word.  Must have BLS Healthcare Provider CPR within first 90 days of employment.  Excellent customer service and organizational skills required.  Needs to be self-directed and able to prioritize.  Able to perform in a fast-paced environment.  Must be able to read, write legibly, speak, and comprehend English. 

WORKING CONDITIONS

WORK CONTEXT

• Physical work conditions (Spend time sitting, spend time standing, Exposed to human body fluids, exposed to chemicals, etc.)
• Interpersonal relationships (Deals with unpleasant people, manages stress, must be helpful, flexible, and assertive with customers, handles conflict with effective problem-solving, functions as a productive team member, must have excellent verbal and written communication skills.
• Structural job characteristics (Importance of being accurate, work schedules, time pressure, etc.)

PHYSICAL FACTORS

• Physical Activities: walking, talking, hearing, bending, twisting, stooping, lifting, kneeling, standing, sitting, crouching, or stooping with good balance for extended periods of time, grasping, pushing, pulling, repetitive motion, using hands to handle, control, or feel objects, tools or controls. 

• Requirements:
  • Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.

OTHER JOB FACTORS

• Speed of Closure, Time Sharing, Finger Dexterity, and Speech Clarity.
• Concern for Others, Cooperation, Dependability, Initiative, Integrity, Self-Control, and Stress Tolerance.
• Independence, Relationships, and Support.