Billing Specialist
OpenLoop
Clinical Due Diligence Review Specialist
Pennant
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- 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
Requirements
- Minimum 5 years of experience in Home Health and/or Hospice, with strong knowledge of CMS Conditions of Payment and Conditions of Participation
- Prior experience with due diligence, compliance, or audit review processes highly preferred
- Proficiency in multiple EMRs, including required experience with HCHB
- Strong ability to interpret and apply data analytics, prepare trending reports, and identify compliance and financial risks
- Demonstrated ability to work independently, exercise sound judgment, and meet deadlines in a fast-paced environment
- Strong written and verbal communication skills, with the ability to present findings to executive leadership
- High attention to detail and ability to identify patterns, trends, and systemic risks
- Proficient in Microsoft Office Suite (Excel, Word, PowerPoint, Smartsheet)
- Flexibility to cross-train in audit review processes and support audit defense activities as part of the broader Denials Management team
- Able to adapt to a fast-paced environment and learn and retain new or evolving information and procedures
