Clinical Reviewer – Utilization Review

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

📋 Description

• Perform thorough evaluations of home health pre-claim review packages to ensure compliance with Medicare coverage, coding, and payment regulations.

• Record affirmation and non-affirmation results along with clinical rationale in the case management system within a timeframe of 7 business days.

• Collaborate with providers to obtain or clarify necessary documentation as permitted.

• Report provider issues or suspected fraudulent activities in accordance with established program protocols.

• Achieve and maintain an accuracy rate of 98%.

• Participate in mandatory training, quality assurance assessments, and inter-rater reliability sessions.

⛳️ Requirements

• Valid and unrestricted RN license in the candidate's state of residence.

• A minimum of 2 years of clinical experience.

• At least 2 years of experience in home health, quality assurance, or utilization review.

• Candidates must reside in and work from an eligible U.S. state at the time of hiring and throughout their employment.

• Experience in home health (OASIS, Medicare Conditions of Participation) or previous involvement with MAC/RCD/CMS program integrity is preferred.

• Proficient in ICD coding is preferred.

• Successful completion of background checks and drug testing prior to employment; some positions may necessitate fingerprinting.

🏝️ Benefits

• 401(k) plan with company matching.

• Paid Time Off (PTO) that increases with tenure.

• Health, Vision, and Dental insurance.

• Company-provided Life Insurance and optional Voluntary Life Insurance.

• Short Term Disability and Long Term Disability coverage.