Home Health and Hospice Medical Review and Appeals Specialist
About The Position
The Medical Review and Appeals Specialist is a registered nurse or licensed practical/vocational nurse who manages medical reviews, Additional Documentation Requests (ADRs), and payer appeals for home health and hospice services. The role ensures documentation accuracy, supports medical necessity, and upholds regulatory compliance to facilitate appropriate reimbursement. The specialist reviews clinical records, prepares appeal letters, and works with clinicians, compliance staff, and billing teams to reduce denials and strengthen documentation practices. The position works with the Lead Medical Review and Appeals Specialist on pre-claim, post-payment, and audit-related reviews; responds to payer-driven reviews; and submits supported appeals. It also tracks appeal outcomes, identifies denial trends, educates clinicians on documentation best practices, maintains knowledge of applicable payer requirements, and helps develop workflows, templates, and tools for the review and appeals process. The role is hybrid-remote, with 90% remote work and 10% in the office in Sandy, Utah, and reports to the VP of Clinical Services.
Requirements
- Active RN or LPN/LVN license in good standing.
- At least 3 years of clinical experience in home health, hospice, or both.
- Knowledge of CMS regulations, Medicare Conditions of Participation, and payer-specific requirements.
- Strong clinical judgment, attention to detail, and analytical skills.
- Excellent written and verbal communication skills, including the ability to draft effective clinical appeals.
- Proficiency with EMRs, Microsoft Office (Excel), and Adobe or Foxit PDF applications.
Nice To Haves
- At least 1 year of experience in utilization review, compliance, or payer appeals.
- Experience responding to TPE, RAC, SMRC, or other federal audit programs.
- Familiarity with OASIS, HIS/HOPE, and other home health and hospice documentation tools.
- Prior experience in compliance, billing, or medical review support.
Responsibilities
- Work with the Lead Medical Review and Appeals Specialist to manage home health and hospice medical reviews, including pre-claim, post-payment, and audit-related reviews.
- Serve as a point of contact for ADRs, TPEs, SMRC, RAC, and other payer-driven reviews.
- Review clinical documentation to confirm services meet payer and regulatory requirements.
- Prepare and submit supported appeal letters and documentation for denied claims, including Levels 1–2 and ALJ hearings as needed.
- Track and maintain detailed records of appeal cases and outcomes.
- Identify denial trends and collaborate with leadership on proactive strategies.
- Provide clinicians with feedback and education on documentation best practices.
- Maintain current knowledge of Medicare, Medicaid, and commercial payer rules relevant to home health and hospice.
- Coordinate with billing, coding, and compliance teams to align documentation and reimbursement.
- Assist in developing workflows, templates, and tools to streamline medical reviews and appeals.
Benefits
- Medical, dental, and vision insurance.
- Flexible Spending and Health Savings options.
- Short- and long-term disability.
- Voluntary life insurance.
- Discounts on pet, auto, and home insurance.
- 401(k) plans with a portion of employee contributions matched by the company.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
