Audit Policy Analyst – Post-Acute Services

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the subject matter expert for DME, home health, and home infusion therapy claims across both government and commercial lines of business.

• Create, maintain, evaluate, and enhance post-acute payment integrity audit concepts.

• Collaborate with operations, clinical, client services, and technology teams to ensure concepts align with coding standards, medical necessity criteria, documentation needs, and payer policies.

• Generate new audit concepts through research, data analysis, claim evaluations, rule documents, and code listings.

• Review and revise audit concepts periodically based on client modifications, regulatory updates, HCPCS changes, DMEPOS fee schedules, and Home Health PPS final regulations.

• Monitor and analyze NCDs, DME MAC LCDs and Policy Articles, Medicare manuals, and CMS transmittals.

• Interpret and implement commercial and Medicaid payer policies across various states and managed care contracts.

• Conduct QA reviews and validate audit logic in accordance with post-acute billing rules and coding standards.

• Identify inconsistencies in concept performance and coordinate resolutions with clinical, coding, and operations teams.

• Oversee multiple audit concept workflows simultaneously, ensuring timely and accurate completion.

• Serve as a point of escalation for intricate DMEPOS, home health, and home infusion documentation and coverage inquiries.

• Develop training materials, job aids, reference tools, and documentation checklists.

• Address client questions and support presentations, provider disputes, and escalations.

• Track concept performance, perform statistical analyses, identify claim-data trends, and propose actions to enhance audit yield and precision.

• Optimize audit workflows, documentation processes, concept tracking, QA methods, and cross-functional collaboration.

• Undertake additional responsibilities and ad hoc projects as assigned.

⛳️ Requirements

• Bachelor’s degree in nursing, health administration, business, or a related field, or equivalent experience.

• At least 5+ years of progressive experience in DME, home health, and/or home infusion therapy, with direct involvement in payment integrity, claims auditing, or provider-side billing and compliance.

• Equivalent experience of 3+ years in post-acute claims auditing and recovery auditing.

• Registered Nurse or Certified Coder with a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required.

• Preferred credentials include home health coding (HCS-D, BCHH-C), OASIS (COS-C), or infusion nursing (CRNI).

• Demonstrated extensive knowledge of ICD-10-CM, HCPCS Level II, CPT, HIPPS, DME fee schedule, Competitive Bidding Program, Home Health PPS under PDGM, and Medicare home infusion therapy benefits.

• Strong understanding of DME MAC jurisdictions, LCDs, Policy Articles, supplier documentation requirements, Standard Written Orders, face-to-face encounters, proof of delivery, continued need, and DME Required Prior Authorization List.

• In-depth knowledge of Medicare home health payment conditions, including homebound status, face-to-face encounter, certification and recertification, plan of care, OASIS assessment, and Notice of Admission.

• Comprehensive knowledge of provider billing guidelines, payer reimbursement policies, medical necessity criteria, and claim adjudication standards for post-acute services.

• Expert in clinical documentation requirements and audit concept development for post-acute claim types.

• Strong background in data utilization and statistical analysis, including the ability to drive scoring and selection for audit concepts.

• Progressive experience in healthcare data analysis and in gathering and documenting requirements for projects of varying scope and complexity.

• Experience in developing clinical content, policy documentation, and training materials.

• Ability to communicate effectively across various organizational levels, diverse teams, and external clients.

• Exceptional written and verbal communication skills with a keen attention to detail.

• Strong critical thinking and analytical capabilities.

• Ability to independently manage multiple workflows in a remote setting and deliver results on time.

• Proficient in Windows office systems and the complete Microsoft Suite, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams.

• Advanced skills in Microsoft Office, especially Excel and PowerPoint.

• Familiarity with encoder and grouper applications, including the Home Health PDGM Grouper.

• Experience working with various software platforms and collaborating with development teams.

• Proven success in a remote working environment.

🏝️ Benefits

• Remote working environment

• Employment at will

• Equal employment opportunity

• Reasonable accommodation during the application or recruitment process