Home Health and Hospice Medical Review and Appeals Specialist

The Medical Review and Appeals Specialist is a registered nurse who manages medical reviews, Additional Documentation Requests (ADRs), and payer appeals for home health and hospice services. This 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 closely with clinicians, compliance staff, and billing teams to minimize denials and strengthen documentation practices.

Key Responsibilities

• Works with the Lead Medical Review and Appeals Specialist to manage the medical review process 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 well-supported appeal letters and supporting documentation for denied claims (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 to develop 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 ensure alignment between documentation and reimbursement.
• Assist in developing standard workflows, templates, and tools to streamline the review and appeals process.

• Registered Nurse (RN) with active license in good standing.
• Minimum of 3 years of clinical experience in home health, hospice, or both.
• At least 1 year of experience in utilization review, compliance, or payer appeals preferred.
• Knowledge of CMS regulations, Medicare Conditions of Participation, and payer-specific requirements.
• Strong clinical judgment, detail orientation, and analytical skills.
• Excellent written and verbal communication, with ability to draft effective clinical appeals.
• Proficiency in EMRs, Microsoft Office and Adobe/Foxit PDF applications.

Preferred Skills

• 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.