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Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in DME, home health, and home infusion therapy claims, with a strong focus on payment integrity and claims auditing. Proficient in developing audit concepts, conducting data analysis, and ensuring compliance with regulatory standards and payer policies.
Highest-signal resume keywords
DME Claims AuditingPayment IntegrityICD-10-CM KnowledgeStatistical AnalysisRegistered Nurse Credential
About the role
Key responsibilities & impact- Serve as the subject matter expert for DME, home health, and home infusion therapy claims across government and commercial lines of business.
- Develop, maintain, test, and optimize post-acute payment integrity audit concepts.
- Partner with operations, clinical, client services, and technology teams to align concepts with coding standards, coverage and medical necessity criteria, documentation requirements, and payer policy.
- Develop new audit concepts through research, data and claim analysis, rule documents, and code lists.
- Review and update audit concepts based on periodic cycles, client changes, regulatory changes, HCPCS updates, DMEPOS fee schedules, and Home Health PPS final rules.
- Monitor and interpret NCDs, DME MAC LCDs and Policy Articles, Medicare manuals, and CMS transmittals.
- Interpret and apply commercial and Medicaid payer policies across multiple states and managed care contracts.
- Perform QA reviews and validate audit logic against post-acute billing rules and coding guidelines.
- Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
- Manage multiple concurrent audit concept workflows and ensure timely, accurate delivery.
- Serve as escalation point for complex DMEPOS, home health, and home infusion documentation and coverage questions.
- Create training materials, job aids, reference tools, and documentation checklists.
- Respond to client inquiries and support presentations, provider disputes, and escalations.
- Monitor concept performance, conduct statistical analysis, identify claim-data trends, and recommend actions to optimize audit yield and accuracy.
- Improve audit workflows, documentation processes, concept tracking, QA processes, and cross-functional coordination.
- Perform additional responsibilities and ad hoc projects as assigned.
Requirements
What you’ll need- Bachelor's degree in nursing, health administration, business, or a related field, or equivalent experience.
- Minimum 5+ years of progressive experience in DME, home health, and/or home infusion therapy, including direct experience in payment integrity, claims auditing, or provider-side billing and compliance.
- Equivalent experience of 3+ years in post-acute claims auditing and recovery auditing.
- Registered Nurse or Certified Coder holding a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required.
- Home health coding (HCS-D, BCHH-C), OASIS (COS-C), or infusion nursing (CRNI) credential preferred.
- Demonstrated depth and breadth of knowledge across ICD-10-CM, HCPCS Level II, CPT, HIPPS, DME fee schedule, Competitive Bidding Program, Home Health PPS under PDGM, and Medicare home infusion therapy benefit.
- Deep understanding of DME MAC jurisdictions, LCDs, Policy Articles, supplier documentation requirements, Standard Written Orders, face-to-face encounters, proof of delivery, continued need, and DME Required Prior Authorization List.
- Deep understanding of Medicare home health conditions of payment, including homebound status, face-to-face encounter, certification and recertification, plan of care, OASIS assessment, and Notice of Admission.
- Broad knowledge of provider billing guidelines, payer reimbursement policies, medical necessity criteria, and claim adjudication standards for post-acute services.
- Expert knowledge of clinical documentation requirements and audit concept development for post-acute claim types.
- Strong experience in data utilization and statistical analysis, including driving scoring and selection for audit concepts.
- Progressive healthcare data analysis experience and experience gathering and documenting requirements for projects of diverse scope and complexity.
- Experience developing clinical content, policy documentation, and training resources.
- Effective communication with organizational levels, diverse teams, and external clients.
- Exceptional written and verbal communication skills with strong attention to detail.
- Excellent critical thinking and analytical skills.
- Ability to manage multiple concurrent workflows independently in a remote environment and deliver results on time.
- Proficiency in Windows office systems and the full Microsoft Suite, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams.
- Advanced Microsoft Office skills, particularly Excel and PowerPoint.
- Familiarity with encoder and grouper applications, including the Home Health PDGM Grouper.
- Experience working with various software platforms and collaborating with development teams.
- Proven success in a remote working environment.
Benefits
Comp & perks- Remote working environment
- Employment at will
- Equal employment opportunity
- Reasonable accommodation during the application or recruitment process
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AuditingPayment IntegrityData AnalysisAudit Concept DevelopmentClinical Documentation RequirementsRegulatory ComplianceHome Health CodingOASIS AssessmentDME Fee Schedule KnowledgePayer Policy Interpretation
Soft Skills
Effective CommunicationAttention to DetailCritical ThinkingAnalytical SkillsIndependent Workflow Management
Tools & Technologies
Microsoft Office SuiteExcelPowerPointSharePointTeamsEncoder ApplicationsGrouper Applications
Certifications & Qualifications
Registered NurseRHIARHITAHIMAAAPCHCS-DBCHH-CCOS-CCRNI
Industry Keywords
DMEHome HealthHome Infusion TherapyMedicareMedicaidPost-Acute ServicesClaims AdjudicationMedical Necessity CriteriaDME MAC LCDsHome Health PPS