Audit Policy Analyst, Post-Acute Services

As part of the Complex Payment Solutions (CPS) Team, the Audit Policy Analyst, Post-Acute Services serves as the subject matter expert for durable medical equipment (DME), home health, and home infusion therapy claims across government and commercial lines of business. This role leads the development, maintenance, testing, and optimization of post-acute payment integrity audit concepts and partners with operations, clinical, client services, and technology teams to ensure each concept is built, validated, and maintained in alignment with coding standards, coverage and medical necessity criteria, documentation requirements, and client-specific payer policy.

The ideal candidate brings authoritative, hands-on knowledge of how post-acute services are ordered, documented, billed, and paid, including DME MAC policy, the Home Health Patient-Driven Groupings Model (PDGM), and the Medicare home infusion therapy benefit. This role requires strong analytical and communication skills, a track record of leading audit concept development, the ability to manage complex workflows independently, and the ability to mentor a team of subject matter experts.

Essential Duties and Responsibilities

Policy Development and Maintenance

• Develop new post-acute audit concepts for DME, home health, and home infusion therapy claims, including research, data and claim analysis, rule documents, and code lists.
• Review and update existing audit concepts on required periodic cycles or in response to client or regulatory changes, including quarterly HCPCS updates, DMEPOS fee schedule updates, and annual Home Health PPS final rules.
• Monitor and interpret changes to National Coverage Determinations (NCDs), DME MAC Local Coverage Determinations (LCDs) and Policy Articles, the Medicare Benefit Policy and Claims Processing Manuals, and CMS transmittals, and document their impact on existing concepts.
• Interpret and apply client-specific commercial and Medicaid payer policy, including home infusion per diem billing, DME rental and purchase rules, and prior authorization requirements.

• Approach for Medicaid audit development in DME and Home Health across multiple states and managed care contracts, the audit program should be built around both federal requirements and state-specific contract obligations.

 

Policy Testing and Validation

• Perform QA reviews of audit concepts to confirm compliance with regulatory, coding, and citation changes and to confirm updates are applied timely.
• Validate concept logic against post-acute billing rules, including DME capped rental and oxygen payment rules, modifier requirements (e.g., KX, GA, GZ, RR, NU, UE), home health 30-day period and LUPA logic, and home infusion therapy visit and drug billing.
• Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
• Ensure audit concepts are validated against current coding guidelines, payment methodologies, and payer policy prior to deployment.

Operational and Workflow Support

• Manage, track, and progress multiple tasks across concurrent audit concept workflows with a high degree of accuracy and quality, delivering results on time.
• Ensure audit teams apply post-acute policies consistently and correctly across auditing platforms and client programs.
• Serve as the escalation point for auditors and clinical reviewers on complex DMEPOS, home health, and home infusion documentation and coverage questions.

Training and Documentation

• Create training materials, job aids, and reference tools for new and existing post-acute audit concepts, including documentation checklists for orders, face-to-face encounters, proof of delivery, homebound status, and plans of care.
• Maintain organized, accessible documentation of post-acute audit policies and concept updates.

Cross-Functional Collaboration and Client Support

• Respond to client inquiries and provide subject matter support to client services for presentations, provider disputes, and escalations involving post-acute claims.
• Partner with operations, clinical teams, technology, and internal stakeholders to support policy execution and drive concept quality.
• Provide expert feedback to improve policy usability, accuracy, and effectiveness across the organization.

Performance Monitoring and Analytics

• Monitor concept performance and provide statistical analysis to drive scoring and selection for new and existing post-acute audit concepts.
• Identify trends in DME, home health, and home infusion claim data, such as utilization outliers, high-cost supply patterns, and billing inconsistencies across care settings, and recommend actions to optimize audit yield and accuracy.

Process Improvement

• Identify opportunities to improve audit concept workflows, documentation processes, and policy management practices.
• Support ongoing enhancements to concept tracking, QA processes, and cross-functional coordination.

Other Duties

• Perform additional responsibilities and ad hoc projects as assigned to meet business needs.

Job Requirements

Education and Experience

• 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.

Knowledge, Skills, and Expertise

• Demonstrated depth and breadth of knowledge across post-acute coding systems and payment methodologies, including ICD-10-CM, HCPCS Level II, CPT, and HIPPS, the DME fee schedule and Competitive Bidding Program, Home Health PPS under PDGM, and the Medicare home infusion therapy benefit.
• Deep understanding of DME MAC jurisdictions, LCDs, Policy Articles, and supplier documentation requirements, including Standard Written Orders, face-to-face encounters, proof of delivery, continued need, and the 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 the 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, including gathering and documenting requirements for projects of diverse scope and complexity.
• Experience developing clinical content, policy documentation, and training resources.
• Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with external clients.
• Exceptional written and verbal communication skills with strong attention to detail.
• Excellent critical thinking and analytical skills.
• Demonstrated ability to manage multiple concurrent workflows independently and in a remote environment, delivering results on time.

Computer Equipment and Software

• Proficient in Windows office systems, including the full Microsoft Suite (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams).
• Advanced skills in Microsoft Office, 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.