Review home health pre-claim review packages to determine whether documentation meets Medicare coverage, coding, and payment criteria. This role centers on documenting affirmation or non-affirmation decisions in a case management system and communicating with providers when additional clarification is needed. It also includes quality-focused review work, escalation of concerns as appropriate, and participation in training and inter-rater reliability activities.
Key Responsibilities
- Conduct comprehensive reviews of home health pre-claim review packages for Medicare coverage, coding, and payment compliance.
- Document review outcomes with clear clinical rationale in the case management system.
- Request or clarify documentation from providers when authorized.
- Escalate provider concerns or suspected fraud according to program procedures.
- Maintain accuracy standards and complete required training, quality assurance reviews, and inter-rater reliability sessions.
Required
- Active, unrestricted RN license in the state of residence.
- At least 2 years of clinical experience.
- At least 2 years of experience in home health, quality assurance, or utilization review.
Preferred
- Experience with home health documentation such as OASIS and Medicare Conditions of Participation.
- Experience with MAC, RCD, or CMS program integrity work.
- Proficiency in ICD coding.
Benefits & Perks
- Annual compensation of $65K.
- 401(k) with company match.
- Health, dental, and vision coverage.
- PTO that increases with tenure.
- Company-provided life insurance, with voluntary life insurance available.
- Short-term and long-term disability coverage.