Home Health/Medicare RCD Clinical Reviewer

Key Responsibilities:

• Conduct comprehensive reviews of home health pre-claim review (PCR) packages to determine compliance with Medicare coverage, coding, and payment criteria.
• Document review outcomes (affirmation/non-affirmation) with well-defined clinical rationale in the designated case management system, ensuring a turnaround time of within 7 business days.
• Engage with providers, as authorized, to request or clarify documentation, and escalate any provider concerns or suspected fraud in accordance with established program procedures.
• Maintain a standard of 98% accuracy and fulfill all required training, quality assurance reviews, and inter-rater reliability sessions.

Minimum Qualifications:

• All RN Medical Reviewers must possess the following minimum qualifications: an active, unrestricted RN license in their state of residence.
• A minimum of 2 years of clinical experience, along with at least 2 years of experience in home health, quality assurance, or utilization review.

Preferred Qualifications:

• Experience in home health (OASIS, Medicare Conditions of Participation) or prior involvement with MAC/RCD/CMS program integrity.
• Proficiency in ICD coding.