Denials Management Specialist

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Pennant

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2016

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Pennant is a company dedicated to providing healthcare services, with a focus on life-changing service, culture, and leadership. They support independent operating subsidiaries that offer home health care, hospice, assisted living, independent living, and memory care. Their mission is to empower local leaders with resources and tools to deliver high-quality care. Pennant operates 103 home health and hospice agencies and 51 senior living communities across several U. S. states, including Arizona, California, and Texas. They emphasize a strong company culture guided by core values that prioritize customer service, accountability, and intelligent risk-taking.

📋 Description

• Perform comprehensive clinical and regulatory reviews of records submitted for payer, government, and external audit requests • Manage assigned audit reviews from intake through submission, including ADR, TPE, UPIC, SMRC, RAC, MAC, Medicaid, managed care, and other payer or regulatory reviews • Review medical records for completeness, accuracy, medical necessity, eligibility, certification/recertification support, plan of care compliance, visit documentation, orders, signatures, and payer-specific requirements • Apply Medicare, Medicaid, payer, hospice, home health, and internal review standards to evaluate claim defensibility • Identify documentation gaps, audit vulnerabilities, technical deficiencies, and recurring denial drivers • Prepare organized audit packets and review summaries for external reviewers, payers, and government contractors • Support appeal development by analyzing denied claims and summarizing clinical and regulatory support • Coordinate audit response activities with agencies, clinical operations, revenue cycle, finance, compliance, and legal teams • Recommend corrective actions, process improvements, and targeted education based on audit findings and risk trends • Maintain proficiency in audit review, tracking, reporting, and healthcare information systems

🎯 Requirements

• Registered Nurse or other applicable clinical licensure strongly preferred • Equivalent clinical, audit, compliance, revenue cycle, or denials management experience may be considered based on business need • Minimum of five years of experience in home health, hospice, post-acute care, clinical documentation review, audit response, appeals, compliance, or denials management preferred • Strong working knowledge of Medicare, Medicaid, managed care, and payer documentation requirements • Knowledge of home health and hospice eligibility, medical necessity, certification, recertification, plan of care, orders, signatures, and visit documentation standards • Ability to interpret payer audit requests and identify required documentation • Ability to evaluate record completeness and organize submission packets accurately and timely • Ability to synthesize complex clinical, operational, and regulatory information into clear findings, recommendations, and education opportunities • Excellent written and verbal communication skills • Highly detail-oriented, deadline-driven, and able to prioritize competing assignments with minimal supervision • Comfortable working independently in a remote environment while collaborating with cross-functional partners • Proficiency with healthcare information systems, electronic medical records, Microsoft Office, Excel, PDF tools, Smartsheet, payer portals, and audit tracking or reporting platforms

🏖️ Benefits

• CAPLICO culture focused on personal and professional development • Equal opportunity employment • Centralized Service Center support including clinical, legal, risk management, HR, training, accounting, and IT resources