Hospice QA & Compliance Specialist

Alliance for Care at Home; Northern (KY); Hybrid; USD 60,000 - 90,000; Full time

Job summary

Alliance for Care at Home is seeking a qualified professional to perform concurrent, pre-billing, and retrospective reviews of hospice and home health records to ensure medical necessity and compliance with Medicare rules. You will assess eligibility, recertification, and documentation, coordinating ADRs, TPE, and appeals where needed.

Applicants should have strong knowledge of CoPs, LCDs, and clinical indicators, with attention to detail and effective education for staff to maintain regulatory

Qualifications

• Minimum 2 years of hospice clinical, QA, compliance, utilization review, or documentation-review experience.
• Strong knowledge of Medicare hospice CoPs, hospice eligibility, certification/recertification requirements, and documentation supporting a terminal prognosis.
• Knowledge of Medicare hospice LCD guidelines and ability to identify objective indicators of disease progression and clinical decline.
• Experience reviewing hospice clinical records for accuracy, completeness, consistency, and compliance, including CTIs, face-to-face encounters, plans of care, IDG documentation, and clinical visit notes.
• Knowledge of Medicare medical review processes, including ADRs, TPE, post-payment reviews, claim denials, and the Medicare appeals process.
• Strong clinical judgment and ability to identify documentation deficiencies, eligibility concerns, and potential compliance or reimbursement risks before claim submission.
• Self-motivated, organized, detail-oriented team member with strong written and verbal communication skills and the ability to provide constructive education and feedback to clinical staff.

Responsibilities

• 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.

Job description

Alliance for Care at Home is seeking a qualified professional to perform concurrent, pre-billing, and retrospective reviews of hospice and home health records to ensure medical necessity and compliance with Medicare rules. You will assess eligibility, recertification, and documentation, coordinating ADRs, TPE, and appeals where needed.

Applicants should have strong knowledge of CoPs, LCDs, and clinical indicators, with attention to detail and effective education for staff to maintain regulatory