Remote Pre-Claim Review Management Specialist, RN/LPN/LVN

Job Overview

  • Clinical License LPN, LVN, RN
  • State(s) Nationwide
Full Job Description

Job Description: Pre-Claim Review Management Specialist


The Pre-Claim Review Management Specialist responds to, monitors and analyzes all governmental requests and demonstration projects regarding Pre-Claim Review by the Medicare Administrative Contractor known as Palmetto GBA. The Essential Functions may be expanded to include ADRs, CERTS, RACs, UPICs, MICs and all other revenue driven denials and requests. The Pre-Claim Review Management Specialist will have the option to expand to their job roles and responsibilities to the Other Essential Functions. Guides and coordinates with the branch staff in developing responses. Identifies the need for changes in policies, procedures, documentation strategies, and protocols based on regulatory requirements and makes recommendations as indicated.

Required Experience:

  • RN requires 2+ years professional experience in Home Health Care
  • LVN/LPN requires 3+ years professional experience in Home Health Care
  • Minimum 1-year experience in an administrative, supervisory or teaching position, or QAPI experience in a Medicare-certified Home Health Care Agency


  • RN, LPN or LVN license in current state
  • PT license in current state
  • Other clinician, as may be appropriate
  • Current driver’s license or government issued ID


  • RN requires bachelor’s or associate degree in Nursing
  • PT requires bachelor’s degree in physical therapy
  • Vocation school required for LPN/LVN

Job Type: Contract

Pay: $25.00 per chart (pay may depend on skills and/or qualifications) for the Pre-Claim Review (PCR)project.
Pay varies for other projects, i.e. responding to ADRs, appeals, etc.

Essential Functions: (Those functions that the individual who holds the position must be able to perform unaided or with the assistance of reasonable accommodation).

  • Utilizes federal guidelines to determine adequacy of documentation to indicate eligibility and medical necessity.
  • Identifies missing or inadequate documentation and requests additional documentation, as required.
  • Collaborates with branch and billing staff to determine appropriate response requiring additional documentation.
  • Identifies tasks and labels accordingly as required for Pre-Claim Review.
  • Collaborates with branch and the billing department to develop appropriate and timely responses to non-affirmations and partial affirmations.
  • Completes the questionnaire as required by Palmetto GBA or other MAC.
  • Identifies the need for new and revised policies, processes and training based on trends, changes in regulations, operations, or clinical programs.

In addition to the Essential Functions, Other Essential Functions Required for ADRs, responses to
UPICs, etc:

  • Responds to denials/non-affirmations, and appeals, utilizing federal guidelines and/or local coverage determination guidelines.
  • Works with branch staff to gather required information and ensure timely response to payor requests for medical records, additional documentation requests, non-affirmations and appeals.
  • Participates in project team activities.
  • Reviews records and operations as requested regarding compliance with policy and payer requirements.
  • Responsible for any assigned tasks inside electronic tracking systems entering data, tracking claims, uploading records and correspondence.
  • Responsible for responding to, managing, and monitoring all Medicare payer government demonstration projects.


  • Thorough knowledge of home health care operations, compliance requirements and legal issues in home care.
  • Expert knowledge of all Medicare home health requirements and federal regulations.
  • Strong analytical skills.
  • Excellent verbal/written communication and presentation skills.
  • Advanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/UPIC and CERT responses (preferred for future opportunities).
  • Must be able to multi-task and work well under pressure.
  • Must have reliable computer and internet. Recommend two monitors for increased efficiency and speed.
  • Able to learn new systems quickly, including HCHB and Adobe DC Pro.
  • Must be proactive, responsive, and resourceful and be diligent in fulfilling commitments.
  • Excellent communication and organization skills.
  • Must read, write and speak fluent English.
  • Must have good and regular attendance.
  • Approximate percent of time required to travel: 0%
  • Performs other related duties as assigned.

Job Type: Contract

Pay: $25.00 – $62.50 per hour


  • Monday to Friday

Pay may depend on skills and/or qualifications


  • LPN/LVN – Professional Home Health Care : 3 years (Required)
  • RN – Professional Home Health Care: 2 years (Required)


  • Nurses (Required)


  • English (Required)

Application Question:

  • This position requires working, reliable computer and internet. Do you have these set up in your home?

Full Time Opportunity:

  • Yes

Work Location:

  • Fully Remote

Company’s website:


Company’s Facebook page:


Work Remotely:

  • Yes

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