Home Health/Medicare RCD Clinical Reviewer
Core
Conduct comprehensive reviews of home health pre-claim review (PCR) packages to determine compliance with Medicare coverage, coding, and payment criteria.
Role type
Clinical reviewer (Medicare compliance)
Builds
Medicare coverage determinations and payment criteria compliance
Domain
Healthcare / Medicare / Home Health
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Active unrestricted RN license, 2+ years clinical experience, 2+ years home health/quality assurance/utilization review experience
Preferred skills
Home health (OASIS, Medicare Conditions of Participation) experience, MAC/RCD/CMS program integrity experience, ICD coding proficiency
Responsibilities
Review PCR packages for Medicare compliance, Document review outcomes with clinical rationale, Engage with providers to clarify documentation, Escalate provider concerns or suspected fraud, Maintain 98% accuracy standard, Complete required training and quality assurance reviews
