Medical Reviewer

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join our elite team of healthcare professionals, providing the Right Care, at the Right Time, in the Right Place.

Job Description:

At Elara Caring, we care where you are and believe the best place for your care is where you live. We know there’s no place like home, and that’s why our teams continue to provide high-quality care to more than 60,000 patients each day in their preferred home setting. Wherever our patients call home and wherever they are on their journey of health, we care. Each team member has a part to play in this mission. This means you have countless ways to make a difference as a Medical Reviewer. Being a part of something this great starts by carrying out our mission every day through your true calling: developing an amazing team of compassionate and dedicated healthcare providers.

To continue to be an industry pioneer in delivering unparalleled care, we need a Medical Reviewer with commitment and compassion. Are you one of them? If so, apply today!

Why Join the Elara Caring mission?

• Work in a collaborative environment.
• Be rewarded with a unique opportunity to make a difference
• Competitive compensation package
• Tuition reimbursement for full-time staff and continuing education opportunities for all employees at no cost
• Opportunities for advancement
• Comprehensive insurance plans for medical, dental, and vision benefits
• 401(K) with employer match
• Paid time off, paid holidays, family, and pet bereavement
• Pet insurance

As a Medical Reviewer you’ll contribute to our success in the following ways:

• Maintains productivity, quality and accuracy targets set by the Governmental Review Manager
• Promotes compliance with all regulatory standards, through review of medical records.
• Participates in the appeals process for claims denied by the government or other payers, as necessary.
• Collects appropriate medical records, reviews the documentation for validity, and submits the requested documents for pre-claim reviews, ADR requests, and/or appeals.
• Responds to questions posed by RCD reviewers timely and accurately, based on regulatory guidance.
• Communicates with agencies related to documentation needs in a timely manner and follows up with agency leadership, as needed.
• Conducts audits of medical record documentation for skilled home health, hospice and PCS as needed to ensure documentation adequacy. 
• Communicates significant findings, problems, and changes related to compliance with documentation standards to the Governmental Review Manager and other personnel involved with patient care. 
• Identifies and communicates to the Governmental Review Manager and other supervisory personnel visit documentation that lacks adequate content to support billing guidelines. 
• Participates in the development of strategies/education to prevent loss of revenue during recovery audits. 
• Assists with development of staff education tools/guides to promote appropriate clinical documentation and utilization. 
• Writes business letters and reports to explain determinations and decisions to a variety of audiences, including, but not limited to governmental payers, private insurance providers, and administrative law judges. 
• Participates in all levels of appeal as needed, using regulatory guidance and critical thinking to navigate appeals compliantly.
• Promotes, coordinates, and evaluates operational Systems to enhance operations and promote efficiencies.
• Provides leadership to team and support staff in identifying agency/client needs and opportunities for improvement.

What is Required?

• Requires a high school diploma or GED.
• Graduated with a diploma from an accredited school as a Licensed Practical Nurse or Licensed Vocational Nurse. 
• Minimum of three (3) years of experience as a licensed practical nurse or licensed vocational nurse in a home health and/or hospice clinical care setting is required.
• Prior functional working experience in medical records review arena (Utilization Review, Case Management and knowledge of appropriate billing and coding guidelines) is preferred.

• Current License as a Licensed Practical Nurse or Licensed Vocational Nurse is required.

You will report to the Governmental Review Manager

Equal Employment Opportunity: We are proud to be an equal opportunity workplace and comply with state and federal affirmative action requirements. Individuals are recruited, hired, assigned and promoted without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, protected veteran status, or any other protected characteristic. If you require assistance due to a disability in the application or recruitment process, please submit a request via email at [email protected].

Pay & Benefit Information: Compensation for this role will be determined based on a variety of factors, including qualifications, skills, competencies, and relevant experience. Elara offers a broad range of benefits. Learn more at https://careers.elara.com/us/en/benefits

EVerify: Elara Caring participates in E-Verify after a job offer is accepted and Form I-9 completed.