Medical Reviewer

• Perform due diligence clinical reviews for home health and hospice acquisitions, ensuring compliance with federal, state, and payer regulations
• Understands and applies COP’s (Medicare guidelines), and all other appropriate CMS or payer program guidelines as it relates to home health care and hospice
• Identify risks that may affect reimbursement, compliance, and clinical outcomes
• Review and analyze records across multiple EMRs, including Homecare Homebase (HCHB) and other common systems
• Comprehend and implement data analytics to generate trending reports, identify systemic risks, and inform leadership decisions
• Create, update, and maintain data analytics platforms to monitor review outcomes and agency risk profiles
• Provide written and verbal reports summarizing findings, including clinical, regulatory, and financial risk insights
• Collaborate with leadership, denials management, and agency partners to recommend corrective actions and process improvements
• Develop and deliver education and training to agencies on documentation best practices, defensible documentation, and regulatory requirements
• Track and trend common deficiencies identified during reviews; escalating systemic issues to leadership
• Participate in cross-training for audit review processes (e.g., RAC, TPE, SMRC, UPIC, Medicare Advantage), supporting the Denials Management team as needed
• Maintain up-to-date knowledge of CMS regulations, industry best practices, and payer requirements
• Contribute to continuous improvement initiatives in due diligence and compliance review processes
• Manage multiple assignments, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload

Clinical Due Diligence Review Specialist

Medical Reviewer II

RN – Medical Claims Reviewer

QHCP Clinical Reviewer – NP, PA, CNM

Genetic Counselor, Clinical Reviewer

Clinical Reviewer