Medical Reviewer

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

📋 Description

• Ensure productivity, quality, and accuracy benchmarks established by the Governmental Review Manager are met.

• Foster adherence to regulatory standards through thorough medical record assessments.

• Gather, verify, and submit medical records for pre-claim reviews, ADR requests, and appeals processes.

• Communicate documentation requirements with agencies and maintain follow-up with agency leadership.

• Conduct audits of medical record documentation for skilled home health, hospice, and PCS services.

• Relay compliance findings and documentation shortcomings to management and patient-care teams.

• Identify visit documentation that fails to provide sufficient content to meet billing criteria.

• Contribute to the development of strategies and educational resources to mitigate revenue loss during recovery audits.

• Assist in creating staff education tools and guides for clinical documentation and utilization.

• Compose business letters and reports detailing determinations and decisions for governmental payers, private insurers, and administrative law judges.

• Engage in all levels of appeals utilizing regulatory guidance and analytical thinking.

• Organize and assess operational systems to enhance efficiency.

• Offer leadership and support in identifying agency/client needs and areas for improvement.

• Report directly to the Supervisor of Pre Claim Review.

⛳️ Requirements

• A high school diploma or GED is mandatory.

• Must possess a diploma from an accredited institution as a Licensed Practical Nurse or Licensed Vocational Nurse.

• A minimum of three (3) years of experience as a licensed practical nurse or licensed vocational nurse in a home health and/or hospice clinical care environment is required.

• Previous hands-on experience in medical records review, utilization review, or case management is preferred.

• Familiarity with appropriate billing and coding guidelines is preferred.

• A current license as a Licensed Practical Nurse or Licensed Vocational Nurse is essential.

🏝️ Benefits

• Competitive compensation package.

• Tuition reimbursement available for full-time employees.

• Continuing education opportunities for all staff at no charge.

• Potential for career advancement.

• Comprehensive medical, dental, and vision insurance options.

• 401(K) plan with employer matching.

• Paid time off benefits.

• Paid holidays.

• Family bereavement leave.

• Pet bereavement leave.

• Pet insurance coverage.