Nurse Reviewer (Hospice)
6 days ago
Baltimore
Job DescriptionDescription: The Hospice Nurse Reviewer applies clinical nursing expertise to review hospice claims, medical records, and provider documentation for compliance with Medicare, Medicaid, and hospice-specific regulatory requirements. This role performs medical necessity reviews, utilization audits, and investigations related to potential fraud, waste, and abuse involving hospice providers, physicians, pharmacies, and suppliers. The ideal candidate is a detail-oriented Registered Nurse with strong hospice, utilization review, and regulatory compliance experience. Responsibilities • Review hospice claims, clinical documentation, and provider records to assess compliance with Medicare and Medicaid hospice regulations., • Conduct medical necessity reviews to determine appropriateness of hospice admissions, recertifications, levels of care, and billed services., • Evaluate beneficiary, provider, and pharmacy cases for potential overpayments, fraud, waste, and abuse., • Perform desk reviews and audits to identify documentation deficiencies, billing inconsistencies, and compliance concerns., • Analyze hospice records including physician certifications, plans of care, IDG notes, eligibility documentation, and supporting clinical records., • Prepare clear, concise case summaries, audit findings, and investigative reports to support compliance reviews and investigations., • Collect, analyze, and document case-specific findings in accordance with contractual and regulatory requirements., • Collaborate with investigators, auditors, compliance teams, and legal stakeholders on complex hospice cases., • Provide clinical expertise to support administrative actions, payment reviews, and corrective action recommendations., • Maintain current knowledge of CMS hospice regulations, Conditions of Participation, LCDs, Medicare Benefit Policy Manual guidance, and billing requirements., • Ensure strict confidentiality and compliance with HIPAA and all data privacy regulations.Requirements: Qualifications • Graduate of an accredited school of nursing; BSN preferred., • Active, unrestricted Registered Nurse (RN) license in state of residence., • Minimum 3–5 years of recent clinical nursing experience, with strong preference for hospice, palliative care, home health, or case management experience., • Experience in utilization review, claims auditing, medical review, compliance, or payment integrity strongly preferred., • Strong knowledge of Medicare hospice benefit requirements, eligibility criteria, documentation standards, and billing practices., • Familiarity with CPT, HCPCS, ICD-10, and hospice coding guidelines preferred., • Coding certification (e.g., CPC, CCS, or hospice-related certification) preferred., • Excellent analytical, critical thinking, investigative, and report-writing skills. 100% Remote PHI/PII Requirement: Yes. The Candidate is required to maintain data security while working in remote workplace. Job Type: Full-time Benefits: • 401(k), • 401(k) matching, • Dental insurance, • Employee assistance program, • Flexible schedule, • Health insurance, • Health savings account, • Life insurance, • Professional development assistance, • Vision insurance