Review home health pre-claim review packages for Medicare coverage, coding, and payment compliance, and document affirmation or non-affirmation decisions with clear clinical rationale. This role also involves contacting providers for documentation clarification when authorized, escalating concerns as needed, and working within quality and accuracy standards in a case management system.
Key Responsibilities
- Conduct comprehensive reviews of home health pre-claim review (PCR) packages for Medicare coverage, coding, and payment criteria.
- Document review determinations with clear clinical rationale in the case management system.
- Provide provider outreach, when authorized, to request or clarify supporting documentation.
- Coordinate escalation of provider concerns or suspected fraud according to program procedures.
- Maintain turnaround time requirements for case reviews.
- Participate in training, quality assurance reviews, and inter-rater reliability sessions.
- Use home health documentation and Medicare criteria to support accurate review decisions.
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
- 1099 contract engagement.
- Remote work.
- Compensation range of $28.85 to $31.25 per hour.
- 401(k) with company match.
- PTO that increases with tenure.
- Health, vision, and dental coverage.
- Company-provided life insurance, with voluntary life options.
- Short-term and long-term disability coverage.