Role Description

We are seeking an experienced and detail-oriented Registered Nurse (RN) OASIS Auditor & Prior Authorization Specialist to support our home health clinical and reimbursement operations. This position is responsible for reviewing OASIS assessments and clinical documentation for accuracy, completeness, regulatory compliance, medical necessity, and consistency with the patient’s Plan of Care. The RN will also coordinate and submit prior authorization requests to Medicaid Managed Care Entities (MCEs) and other insurance payers.

The ideal candidate has strong home health clinical experience, excellent documentation-review skills, working knowledge of OASIS requirements, and experience supporting prior authorization and medical necessity determinations.

Key Responsibilities

• OASIS Auditing & Clinical Documentation
  • Review SOC, ROC, Recertification, Transfer, and Discharge OASIS assessments for accuracy and completeness.
  • Audit OASIS documentation for consistency with the comprehensive assessment, diagnoses, functional status, skilled needs, homebound status, and Plan of Care.
  • Identify documentation discrepancies, missing information, inconsistencies, and potential compliance concerns.
  • Provide clinicians with clear corrections and recommendations before final submission when appropriate.
  • Review documentation for appropriate support of skilled nursing, therapy, and home health aide services.
  • Monitor documentation and OASIS completion timeliness.
  • Assist with preparation for regulatory surveys, internal audits, QAPI activities, and payer reviews.
  • Educate clinical staff regarding documentation deficiencies and opportunities for improvement.
• Prior Authorization
  • Prepare, submit, and track prior authorization requests for home health services.
  • Review clinical documentation to ensure requested services and hours are supported by the patient's medical condition, functional limitations, safety risks, and skilled-care needs.
  • Develop strong medical-necessity summaries supporting requested services, frequency, duration, and increases or extensions of care.
  • Submit required clinical documentation to Medicaid MCEs, Medicare Advantage plans, and other applicable payers.
  • Track authorization expiration dates, approved units/hours, pending requests, requests for additional information, denials, and appeals.
  • Communicate with physicians, nurses, therapists, scheduling, billing, and payer representatives regarding authorization requirements.
  • Assist with reconsiderations, peer-to-peer reviews, and appeals when authorization requests are reduced or denied.
  • Maintain organized documentation of payer communications and authorization decisions.
  • Help prevent unauthorized visits and interruptions in patient care by proactively monitoring authorization periods.

Qualifications

• Current, unrestricted Registered Nurse (RN) license.
• Home health nursing experience strongly preferred.
• OASIS experience required; OASIS auditing/review experience preferred.
• Knowledge of Medicare and Medicaid home health documentation requirements.
• Prior authorization or utilization-review experience strongly preferred.
• Ability to interpret clinical records and clearly demonstrate medical necessity.
• Strong understanding of Plans of Care, physician orders, skilled nursing documentation, functional limitations, and homebound criteria.
• Excellent written communication, organization, and attention to detail.
• Ability to communicate documentation deficiencies professionally with clinical staff.
• Experience with home health EMR systems preferred.

Preferred Experience

• Experience with Indiana Medicaid, Managed Care Entities (MCEs), Medicare/Medicare Advantage, OASIS, home health Plans of Care, utilization management, medical-necessity documentation, and payer authorization processes is highly desirable.
• Flexible work from home options available.