01/01/76 A

Plans, organizes and directs a quality assurance and utilization review program within a State general hospital.

The work includes responsibility for establishing and supervising quality assurance and utilization review units which render decisions relative to pre-admissions screening, admissions necessity certification, discharge planning and development of criteria for medical care evaluation; developing and coordinating efforts of professional committees toward development and revision of quality assurance and utilization review criteria to meet State, Federal and institutional regulations and needs; development and implementation of procedures to expedite and report on quality assurance activities; cooperative means of assuring the maintenance of quality assurance data; and the education of physicians and others in the necessity of methodology of quality assurance and utilization review. In the more complex unprecedented cases, decisions are made as to the necessity of admissions, extensions of stay and services rendered patients, and efforts are made to have the appropriate criteria established. Decisions as to program administration are made in accordance with the institution’s overall administrative policies. Direction is received from a professional or administrative director charged with overall direction of the institution’s utilization review and quality assurance programs.

Examples of duties characteristic of positions in this class:

Plans, organizes and directs a quality assurance program within a State general hospital; sets up operating units for prospective review, concurrent review and retrospective review functions relating to admission request, pre-admission clinical testing, admission necessity certification, length of stay review, discharge planning, evaluation of utilization review, continuing criteria development and education.

Renders decisions on unusual problems that involve policy interpretations or consults with medical staffs and hospital direct for advice on problems requiring medical and/or procedural knowledge.

Continuously evaluates procedures to provide more efficient methods; revises reporting forms to provide for more complete and condensed data; consults with proper committees in the distribution and filing of information.

Establishes safeguards to preserve the confidentiality of information from the patient medical records or other sources of patient information, assists authorized personnel in the implementation and use of quality assurance data and reports.

Consults with the medical staff and hospital administrators on revisions of reports, seeks cooperation of medical staff in recording and completing medical records of patients to adequately document data necessary for quality assurance evaluations.

Reviews the data on a non-routine basis, contacts attending physicians or refers to physician reviewer when necessary; assists authorized non-hospital organizations such as Federal, State, professional regulating groups and third-party payers in determining hospital compliance with their respective regulations and standards.

Coordinates at the administrative level with admissions, credit offices, medical records department, social services, and professionals including physicians, nurses, dietitians and therapists in the interchange of necessary information in carrying out the quality assurance program.

High school graduation and six years of experience in quality assurance, nursing, medical records administration or a related field, one year of which was in a supervisory or administrative capacity. Education in nursing, medical records administration or related fields may be substituted for experience on an equivalent time basis provided no substitution is allowed for supervisory or administrative experience.

Considerable knowledge of the symptomology and treatment of illnesses, hospital organization, patient care processes, medical records and terminology, coding and classification of diseases, diagnostic and laboratory reports and their interpretation, and rules and regulations relating to quality assurance and utilization review; ability to work effectively with physicians, support, and administrative; ability to organize, coordinate and supervise an institutional program.