Medical Reviewer - Home Health and Hospice

Job Details Job Location Cantex Corporate - Carrollton, TX Position Type Full Time Job Category Compliance Description Role will be based in Dallas, Tx with travel to Houston, San Antonio and East Texas The Medical Reviewer - Home-Based Care Services (HCBS) is responsible for ensuring accurate documentation, coding, and billing practices within Thera Care Home Health and Elysian Hospice. This role supports the Revenue Compliance and Reimbursement teams by safeguarding company revenue and ensuring strict adherence to all applicable federal and state regulations, including CMS, OIG, and Local Coverage Determinations. The Analyst acts as a liaison between payers, providers, and billing teams, with a primary focus on Home Health and Hospice settings.

Qualifications

Key Responsibilities: Auditing & Monitoring:

• Perform targeted and periodic audits in Home Health and Hospice agencies with high error rates or financial risk.
• Ensure clinical documentation supports medical necessity, level of care, and accuracy of coding (ICD-10, CPT, HHRG, HIPPS, etc.).
• Confirm Home Health documentation meets:
• Face-to-Face Encounter requirements
• OASIS data accuracy
• Plan of Care (POC) compliance
• Validate Hospice documentation for:
• Accurate certification of terminal illness
• Appropriately documented decline and prognosis
• Correct election and level of care per Medicare guidelines and LCDs
• Review claim submissions, denials, and appeals to identify trends and recommend corrective actions.
• Provide detailed feedback post-audit and support ongoing documentation improvement.

Appeals & Documentation Review:

• Complete and review:
• Additional Documentation Requests (ADRs)
• Appeals
• Quality of Care (QOC) reviews
• Risk Analyses (RA) from Medicare and Managed Care Payers
• Draft Medical Necessity summaries and ensure timely and accurate submission of:
• Home Health RAPs and Final Claims
• Hospice NOEs, NOTRs, and Final Claims
• Monitor and track the outcomes of all appeal and audit activity.
• Coordinate and respond to government and payer probes; assist with education and corrective action planning.

Education & Communication:

• Collaborate with the Compliance Department to conduct internal audits and identify areas for improvement.
• Assist in the training of clinical and billing teams on compliance standards, PDGM, and Medicare Hospice Benefit requirements.
• Maintain open, professional communication with internal staff, leadership, payers, and regulatory bodies.
• Deliver feedback, reports, and recommendations to the Revenue Compliance Manager and executive leadership.

Process & Reporting:

• Maintain accurate records of all audits and appeal activity.
• Submit reports regularly to the Revenue Compliance Manager, VP of Home Care-Based Services, and other leadership as needed.
• Conduct in-depth regulatory research related to payment policy, CMS updates, and payer requirements.

Qualifications:

• Licensure: RN, LVN, OTR, PT, or SLP

Experience:

• Minimum 5 years of clinical experience in post-acute care, including Home Health and Hospice
• Experience with PDGM, OASIS, Hospice Conditions of Participation, Medicare documentation and billing
• Certification:
• Coding certification required (e.g., CRC, CCS, CPC, HCS-D, HCS-H)

Education:

• Bachelor's, Master's, or Doctorate in a healthcare or clinical field preferred (or equivalent experience)

Knowledge:

• Strong understanding of CMS Conditions of Participation for SNF, Home Health, and Hospice
• Proficient with Medicare billing, compliance requirements, and denial managements

Preferred Continuing Education & Training:

• RAC-CT Certification via AANAC
• ICD-10 Coding Boot Camps
• PDGM and Hospice regulatory training courses
• Medicare and RAC Audit Seminars
• CMS Open Forums on Denials, Appeals, and Documentation Standards

We are an Equal opportunity employer; We offer an excellent benefit plan to include 401K with match, CEU reimbursement, vacation, sick, holidays, medical, dental, and supplemental insurance Plans as well as a Highly competitive compensation package. Diversity, Equity and Inclusion are at the heart of Pivot Rehab. We are committed to a culture that respects our differences and values the contribution of all people. #Corp Apply tot his job Apply To this Job