Clinical Review Specialist - LPN

Are you looking to make a difference in patients’ lives with a company that values your expertise? Join us in our mission of delivering compassionate healthcare where it matters most –– at home.

Pinnacle Home Care, Florida’s largest Medicare-certified home health provider, has been delivering high-quality, patient-centered care for over two decades, and we’re looking for a Clinical Review Specialist to join our award-winning team.

Key Responsibilities

• Review new patient referrals for medical necessity, skilled service needs, and compliance with payer and regulatory requirements.
• Verify Face-to-Face (F2F) encounter documentation is complete, timely, and compliant.
• Confirm and document the attending physician who will sign and oversee the plan of care.
• Request additional orders when identified during referral review.
• Identify and upload applicable clinical protocols to the patient’s record.
• Plot visit frequencies and disciplines based on referral data, physician orders, payer guidelines, and industry best practices.
• Ensure visit plans are appropriate for the patient’s diagnosis, functional status, and goals.
• Evaluate planned services for fiscal soundness, ensuring visit utilization aligns with payer requirements and agency reimbursement models.
• Monitor referral documentation and care plans to prevent unnecessary financial risk, denials, or write-offs.
• Support revenue cycle accuracy by validating compliance with billing requirements, payer coverage rules, and agency contracts.
• Collaborate with clinical and operational leadership to ensure cost-effective care delivery while maintaining quality standards.
• Maintain current knowledge of federal, state, and payer-specific regulations impacting home health.
• Ensure all documentation and care planning meets CMS Conditions of Participation (CoPs), state regulations, and accrediting body standards.
• Support internal audits, quality reviews, and corrective action plans as needed.

Qualifications

• Active, unrestricted LPN license in the state(s) served.
• Minimum 2 years of recent experience in home health clinical practice, utilization review, or compliance auditing.
• Strong knowledge of:
  • Home health regulations (CMS, state, accrediting bodies).
  • Payer requirements and insurance authorization processes.
  • Reimbursement models (episodic, per-visit, and managed care).
• Demonstrated ability to balance clinical decision-making with fiscal stewardship.
• Excellent analytical, compliance, and problem-solving skills.
• Effective communication and interpersonal skills with physicians, staff, and payers.
• Detail-oriented with a focus on accurate, compliant documentation.
• Ability to work independently in a challenging environment while collaborating with interdisciplinary teams.
• Strong organizational skills with the ability to prioritize and manage multiple tasks.

Why Choose Pinnacle?

Personalized, One-on-One Care: Help patients heal and regain their independence by delivering individualized care in the comfort of their homes.

Growth & Stability: Over two decades as Florida’s largest home health agency.

Ongoing Professional Development: Free Continuing Education Units (CEUs) to support licensure and career advancement.

Competitive Benefits & Perks: Including Daily Pay (work today, get paid tomorrow!) and an employee referral program where you can earn rewards.

Recognized Excellence: Ranked as a USA Today Top Workplace.

Flexible Scheduling: Enjoy a schedule that aligns with your personal priorities.

Supportive & Fun Culture: Join a collaborative, forward-thinking team that values both professional excellence and personal fulfillment.

Pinnacle promotes an inclusive environment and is an equal opportunity employer. We prohibit discrimination or harassment based on race, religion, age, gender, national origin, disability, veteran status, or other legally protected characteristics.

Be part of a company that empowers clinicians to make a difference in the lives of over 10,000 patients across Florida every day. Apply now!