Quality Assurance - Home Health and Hospice

QUALIFICATIONS:

• 3–5 years of hospice experience in clinical care, case management, QA, compliance, or leadership.
• Previous experience preparing and reviewing hospice ADR submissions, TPE responses, post-payment reviews, and Medicare appeals.
• Experience performing hospice eligibility, recertification, pre-billing, and retrospective clinical record audits.
• Home health QA experience with knowledge of Medicare home health documentation requirements.
• Working knowledge of ICD-10-CM coding, hospice diagnosis selection, and home health coding/OASIS requirements.
• Experience identifying denial trends, performing root-cause analysis, developing corrective-action plans, and providing staff education.
• Hospice, home health, coding, quality, or healthcare compliance certification/training preferred.

SUPERVISED BY:

Director of Nursing and Executive Director

JOB DESCRIPTION:

• Conduct concurrent, pre-billing, and retrospective review of hospice and home health clinical records to ensure completeness, accuracy, consistency, medical necessity, and compliance with Medicare requirements and agency standards.
• Perform hospice eligibility and recertification reviews, evaluating documentation for objective evidence of terminal decline, appropriate primary and related diagnoses, disease-specific LCD criteria when applicable, PPS/KPS/FAST and other clinical indicators, and documentation supporting a prognosis of six months or less.
• Coordinate and perform clinical record review for Medicare Additional Documentation Requests (ADRs), TPE, post-payment reviews, denials, and appeals; identify documentation deficiencies and assist with preparation of complete, organized, and defensible medical-record submissions within required deadlines.
• Review hospice documentation for consistency across the Certification of Terminal Illness (CTI), face-to-face encounters, comprehensive assessments, plans of care, IDG documentation, physician/NP documentation, nursing notes, and other clinical records; communicate deficiencies and provide education to clinical staff when corrective action is needed.
• Review home health records for completeness, accuracy, medical necessity, and consistency of OASIS responses with the clinical record; perform ongoing audits and support agency quality improvement and performance activities.
• Assign and/or validate ICD-10-CM codes and diagnosis sequencing as appropriate and serve as a clinical documentation, coding, hospice eligibility, and Medicare compliance resource for agency clinical and administrative personnel.
• Collaborate with the Director of Clinical Services, Administrator, and clinical leadership to identify audit and denial trends, implement corrective actions, provide staff education, and support ongoing regulatory readiness; perform field visits, weekend rotation, and other duties as assigned when necessary.