Due Diligence Clinical Review Specialist

📋 Description

• • Join The Pennant Group, Inc., a rapidly expanding leader in the senior living, home health, hospice, and home care industries, and contribute to our mission of providing life-changing services and professional expertise.
• • As a Due Diligence Clinical Review Specialist, you will be instrumental in evaluating clinical, regulatory, and operational compliance risks associated with home health and hospice acquisitions, ensuring our continued commitment to excellence and compliance.
• • This pivotal role involves conducting in-depth clinical documentation and compliance reviews, with a sharp focus on the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COP) and Conditions of Payment.
• • You will be a key player in safeguarding the company against potential risks, ensuring that all acquired entities meet stringent federal, state, and payer regulations.
• • The ideal candidate is a highly motivated clinician with a proven track record in multi-Electronic Medical Record (EMR) systems, including significant experience with Homecare Homebase (HCHB).
• • Your ability to comprehend and apply data analytics will be crucial for generating trending reports, identifying systemic risks, and providing actionable insights to leadership.
• • You will assess clinical risk, pinpoint compliance gaps, and formulate strategic recommendations to enhance operational integrity and financial health.
• • A core responsibility includes ensuring strict adherence to the CAPLICO Core Values (Customer Second, Accountability, Passion for Learning, Love One Another, Intelligent Risk Taking, Celebrate, Ownership) and the Code of Conduct in all aspects of your work.
• • You will perform comprehensive due diligence clinical reviews for home health and hospice acquisitions, meticulously verifying compliance with all relevant federal, state, and payer regulations.
• • A deep understanding and application of Medicare guidelines (COP's) and all other appropriate CMS or payer program guidelines as they relate to home health care and hospice services are essential.
• • Your analytical skills will be employed to identify risks that could potentially impact reimbursement, compliance status, and overall clinical outcomes for acquired agencies.
• • You will be adept at reviewing and analyzing patient records across various EMR platforms, demonstrating proficiency with HCHB and other commonly used systems.
• • A significant part of your role will involve comprehending and implementing data analytics to generate insightful trending reports, identify overarching systemic risks, and inform critical leadership decisions.
• • You will be responsible for creating, updating, and maintaining data analytics platforms to effectively monitor review outcomes and assess agency risk profiles.
• • Prepare and deliver clear, concise written and verbal reports that summarize your findings, offering critical insights into clinical, regulatory, and financial risks.
• • Collaborate effectively with leadership, the denials management team, and agency partners to propose and implement corrective actions and drive process improvements.
• • Develop and deliver targeted education and training programs to agencies, focusing on best practices in documentation, defensible documentation strategies, and adherence to regulatory requirements.
• • Track and trend common deficiencies identified during reviews, proactively escalating systemic issues to leadership for timely resolution.
• • Participate in cross-training for various audit review processes (e.g., RAC, TPE, SMRC, UPIC, Medicare Advantage), providing essential support to the Denials Management team as needed.
• • Maintain an up-to-date knowledge base of CMS regulations, evolving industry best practices, and specific payer requirements to ensure ongoing compliance and accuracy.
• • Contribute actively to continuous improvement initiatives aimed at refining and enhancing our due diligence and compliance review processes.
• • Demonstrate exceptional organizational skills, with the ability to effectively manage multiple assignments, create detailed documentation of findings and suggestions, and prioritize workload efficiently.
• • Exhibit a high degree of flexibility and motivation, with the capacity to work both independently and collaboratively within a team setting to achieve collective goals.
• • This role is critical in ensuring the smooth integration of acquired entities and upholding the high standards of clinical quality and regulatory compliance that define The Pennant Group.
• • You will be a trusted advisor, providing essential clinical and compliance expertise that supports strategic growth and operational excellence.
• • Your work will directly impact the company's ability to mitigate risk, optimize reimbursement, and maintain a strong reputation in the healthcare sector.
• • Embrace a culture of continuous learning and improvement, staying ahead of regulatory changes and industry trends.
• • This is a remote position, offering the flexibility to work from anywhere in the USA while being an integral part of our world-class Service Center team.