This position is a remote position. It can be located anywhere in the U.S.
Responsible to respond to, monitor and analyze all governmental requests, including but not limited to Additional Development Requests (ADRs), CERTS, Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs), Supplement Medicare Recovery Contractors (SMERCs), Unified Program Integrity Contractors (UPICs) and all other revenue-driven denials and requests. Guides and coordinates with the program staff in developing responses. Identifies the need for changes in policies, procedures, documentation strategies, and protocols based on regulatory requirements and makes recommendations as indicated.
Essential Functions:
Responsible for responding to, managing and monitoring all payer requests for additional documentation (ADR) and denials. Works with program staff to gather required information and ensure timely response to payer requests for additional documentation.
Monitors denials, collaborates with program and billing staff to determine appropriate response, manages appeals process.
Monitors and responds to all requests related to revenue recovery including but not limited to Government and private payer requests.
Collaborates with program and billing department staff to develop appropriate and timely responses.
Responsible for constructing response to denials and appeals, utilizing any federal and state guidelines and local coverage determination guidelines that are applicable to the record and response.
Monitors the development, interpretation and implementation of federal and state governmental regulations. Coordinates the dissemination of information to program management and regional leadership.
Provides trended reports for operations and clinical management in order to improve performance, collaborates with and acts as a resource for division and field support staff in identifying areas in need of attention/improvement.
Identifies the need for new and revised policies and training based on trends, changes in regulations, operations or clinical programs.
Participates in project team activities, and serves as a backup to Divisional regulatory staff on issues of regulations, coverage, compliance and documentation.
Reviews records and operations as requested regarding compliance with policy and payer requirements.
Responsible for assigned tasks within requests tracking system: entering, tracking, uploading records, etc.
Participates in and provides training as assigned.
Education:
Registered Nurse
Licenses/Certification:
Current state license as a Registered Nurse.
Current drivers license. Must have reliable transportation and insurance.
Experience:
5 years of professional experience in home health, 2 of which are in an administrative, supervisory, or teaching position in or related to a Medicare certified home health agency.
Knowledge/Skills/Abilities:
A thorough knowledge of federal regulations and Medicare requirements is required along with analytical skills to interpret and apply regulatory requirements.
Extensive knowledge of home health operations, compliance requirements and legal issues in home health
Extensive experience in working with payer requirements, ADR requests, Denials, Appeals, RAC, ZPIC, CERT, etc. responses
Excellent written and verbal communications skills.
Must be able to multi-task and work well under pressure.
Must be able to learn medical record and tracking systems quickly and extensively.
Must be proactive, responsive and resourceful.
Highly flexible and motivated with an ability to work independently as well as in a team setting.
Must consistently demonstrate the highest level of professionalism and discretion.
Ability to work a flexible schedule and extended hours on occasion in order to meet deadlines and/or work on special projects.
Requires working under some stress conditions to meet deadlines and agency needs.
