Minimum 2 years of hospice clinical, Quality Assurance, compliance, utilization review, or documentation-review experience.
Strong knowledge of Medicare hospice Conditions of Participation (CoPs), hospice eligibility, certification/recertification requirements, and documentation supporting a terminal prognosis.
Knowledge of Medicare hospice LCD guidelines and ability to identify objective indicators of disease progression and clinical decline.
Experience reviewing hospice clinical records for accuracy, completeness, consistency, and compliance, including CTIs, face-to-face encounters, plans of care, IDG documentation, and clinical visit notes.
Knowledge of Medicare medical review processes, including ADRs, TPE, post-payment reviews, claim denials, and the Medicare appeals process.
Strong clinical judgment and ability to identify documentation deficiencies, eligibility concerns, and potential compliance or reimbursement risks before claim submission.
Self-motivated, organized, detail-oriented team member with strong written and verbal communication skills and the ability to provide constructive education and feedback to clinical staff.
PREFERRED QUALIFICATIONS
3–5 years of hospice experience in clinical care, case management, QA, compliance, or leadership.
Previous experience preparing and reviewing hospice ADR submissions, TPE responses, post-payment reviews, and Medicare appeals.
Experience performing hospice eligibility, recertification, pre-billing, and retrospective clinical record audits.
Home health QA experience with knowledge of Medicare home health documentation requirements.
Working knowledge of ICD-10-CM coding, hospice diagnosis selection, and home health coding/OASIS requirements.
Hospice, home health, coding, quality, or healthcare compliance certification/training preferred.
JOB DESCRIPTION
Conduct concurrent, pre-billing, and retrospective review of hospice and home health clinical records to ensure completeness, accuracy, consistency, medical necessity, and compliance with Medicare requirements and agency standards.
Perform hospice eligibility and recertification reviews, evaluating documentation for objective evidence of terminal decline, appropriate primary and related diagnoses, disease-specific LCD criteria when applicable, PPS/KPS/FAST and other clinical indicators, and documentation supporting a prognosis of six months or less.
Coordinate and perform clinical record review for Medicare Additional Documentation Requests (ADRs), TPE, post-payment reviews, denials, and appeals; identify documentation deficiencies and assist with preparation of complete, organized, and defensible medical-record submissions within required deadlines.
Review hospice documentation for consistency across the Certification of Terminal Illness (CTI), face-to-face encounters, comprehensive assessments, plans of care, IDG documentation, physician/NP documentation, nursing notes, and other clinical records; communicate deficiencies and provide education to clinical staff when corrective action is needed.
Review home health records for completeness, accuracy, medical necessity, and consistency of OASIS responses with the clinical record; perform ongoing audits and support agency quality improvement and performance activities.
Assign and/or validate ICD-10-CM codes and diagnosis sequencing as appropriate and serve as a clinical documentation, coding, hospice eligibility, and Medicare compliance resource for agency clinical and administrative personnel.
Collaborate with the Director of Clinical Services, Administrator, and clinical leadership to identify audit and denial trends, implement corrective actions, provide staff education, and support ongoing regulatory readiness; perform field visits, weekend rotation, and other duties as assigned when necessary.
Job details are sourced from the employer's original posting.
