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 maintains regulatory compliance to facilitate appropriate reimbursement. The specialist reviews clinical records, prepares appeal letters, and works with clinicians, compliance staff, and billing teams to minimize denials and strengthen documentation practices. The position is hybrid-remote, with 90% remote work and 10% in the Sandy, Utah office. It 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 in 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 is preferred.
- 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 medical reviews for home health and hospice cases, 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, monitor, and maintain detailed records of appeal cases and outcomes.
- Identify denial trends and collaborate with leadership on proactive strategies.
- Partner with clinicians to provide 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 standard workflows, templates, and tools to streamline the review and appeals process.
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
- Perks on Larry H. Miller Megaplex Theaters
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
