Division Manager of Clinical Review

It's fun to work in a company where people truly BELIEVE in what they're doing!

Our intention is to have employees who are passionate about making their personal mission statement come to life each day at work!  Be it through providing healing, eradicating loneliness, contributing to efficiencies, streamlining processes, being dependable, sparking creativity or something else, the demonstration of HOW you do your job is just as important as WHAT you do in your job.

Alongside our valued employees, we are making a difference throughout the state of Ohio in the lives of those that need healthcare or those embracing the next chapter of their lives. Sustained members of our team demonstrate accountable behavior and share our values of customer service, innovation, integrity, financial stewardship, inclusion, leadership and care.

The Division Manager of Clinical Review provides leadership and strategic oversight to the Clinical Review team in accordance with company standards and federal, state, and local standards, guidelines, and regulations.

Essential Activities and Tasks 

Clinical Practice and Documentation - 50%

• In partnership with the location Executive Directors and site leadership, this position oversees and ensures timely processing of Home Health Starts of Care (SOCs), Hospice Admissions, Plans of Care (POCs), recertifications, Resumption of Care (ROCs), discharges, and related documentation across assigned offices, maintaining team productivity within accepted benchmarks.

• Leads review and approval of evaluation documentation, OASIS assessments, 485s, HOPE assessments, and other clinical information collected by assessing clinician during the in-home comprehensive assessment to ensure accuracy.. 

• Directs team processes for ICD-10 coding accuracy, corrections, follow-up on required documentation, service utilization correlation with assessment data, selection of appropriate care types/POCs based on patient condition, and verification of episode dates, supplies, medications, functional limitations, allergies, action screen items, and other elements.    

• Monitors and ensures POC completion/reassessment by appropriate professionals following significant health status changes, hospital discharges, physician requests, or transfers to inpatient facilities, with proper documentation.                 

People Management and Development - 20%

• Supervises the Clinical Reviewers.

• Fosters a positive work environment that attracts, retains, and motivates employees.

• Interviews, selects, and orients new direct reports.

• Defines, establishes, and promotes performance expectations so direct reports understand and demonstrate excellence through high quality and consistent performance.

• Evaluates job performance of direct reports in accordance with the company policy and procedure and provides developmental guidance to staff for improved performance and growth.

• Monitors accountability with organization requirements prescribed by the Employee Handbook.  Documents and engages employees who are routinely not observing these requirements in an effort to achieve compliance.  Works with Human Resources when circumstances arise that necessitate further documentation and intervention.

• Participates in the development, planning, scheduling, conducting, and monitoring of in-service training programs, on-the-job training, and orientation programs for departmental staff.

• Ensures that there is a reasonable and sufficient plan for staffing should a direct report be absent or a direct reporting position be vacant.

• Responds timely and thoughtfully to questions, requests, and work product from departmental staff that have been provided for review and approval.

Quality Assurance, Auditing, and Performance Improvement - 10%

• Develops, updates, and maintains audit tools, checklists, review processes, and quality benchmarks for all regulatory and quality reviews. 

• Conducts and oversees audits of team work to assess accuracy, compliance, and quality; tracks and analyzes metrics (e.g., error rates, process measures, outcome achievements, star rating impacts). 

• Identifies trends/root causes and leads targeted performance improvement initiatives, process redesign, corrective actions, and education to significantly enhance quality outcomes and compliance.

Education, Training, and Resource Support - 10%

• Designs and delivers ongoing education/training to Clinical Reviewers, field staff, clinical supervisors, and site leadership on OASIS, HOPE, ICD-10 best practices, documentation standards, regulatory updates, and quality improvement.

• Serves as the primary clinical resource for coding, documentation, OASIS/HOPE accuracy, and related issues; identify and address training needs. 

• Participates in orientation of new Clinical Reviewers and assist with job-specific training as needed.

Compliance and Regulatory Management - 5%

• Ensures team maintains current, accurate records in accordance with company standards, federal/state/local regulations, accrediting bodies, and third-party payers. 

• Stays proficient in requirements of regulatory agencies and collaborate with the Corporate Manager of Quality and Compliance on audits, surveys, and corrective plans.

Dynamic Workflow Contributions - 5%

• Assists with additional clinical operations workflows, special projects, or priorities as assigned by the Director of Clinical Operations, applying expertise to support organizational goals.

All other duties as assigned.

Qualifications

Education

• Associate's degree in nursing required.

• Bachelor's degree in nursing preferred.

• Current unencumbered license for the state of Ohio to practice as a Registered Nurse (RN) required. 

• Certification in ICD-10 diagnosis coding required or willingness to obtain within six months of hire.

• Certification as an OASIS Specialist-Clinical (COS-C) or equivalent (e.g., from OCCB or similar competency board) strongly preferred.

Experience

• Three years clinical experience in home health.

• Two years experience in OASIS assessments, ICD-10 coding, clinical documentation review, or quality auditing. 

• Experience in a Medicare-certified home health/hospice agency required.

• Prior supervisory, leadership, or team management experience strongly preferred. 

• Advanced proficiency in current OASIS, HOPE, ICD-10 guidelines, CMS regulations, and quality metrics. 

• Proficiency with Windows, Microsoft Office (Word, Excel, PowerPoint), electronic health records, CMS systems (e.g., iQIES), and internet tools. 

Other Requirements

• Must be able to read, write, speak, and understand the English language.

• Must possess a valid driver's license and acceptable driving record. Must be insurable under professional liability and crime coverage policies as specified by insurance carrier underwriting standards.

Working Conditions and Special Requirements

• Sitting - Up to 8 hours/day

• Standing - Up to 2 hours/day

• Walking - Up to 2 hours/day

• Lifting, pushing, pulling, and moving equipment, supplies, etc. - Up to 25 pounds

• Risk Category for Exposure to Bloodborne Diseases - III