Healthcare Audit Recovery Analyst

Performant•Plantation, FL

2d•$54,200 - $67,000•Remote

About The Position

The Healthcare Audit Recovery Analyst is responsible for objectively and accurately completing claim audit reviews on assigned Medicare (State) audits while meeting quality and productivity performance goals, as required. This position makes determinations based on claims payment expertise and knowledge while utilizing audit tools and resources available. This role is also responsible for communicating and supporting the identification of additional audit opportunities and participating in development of new ideas, as necessary.

Requirements

High School Diploma is required.
3+ years healthcare claims processing with experience in Medicaid claims
3+ years of experience in the health care industry, preferably in an auditing role
3+ years working with health care claims demonstrating expertise in, ICD-9/ICD-10 coding, HCPS/CPT-4 coding, and MS-DRG including medical billing experience for an Insurance Company or hospital
Ability to be flexible and seizes the opportunity to cross train
Ability to maintain high quality work while meeting deadlines and performance metrics
Excellent organizational, interpersonal and communication skills
Strong problem solving skills
Excellent organizational, interpersonal and communication skills
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings
Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members
Acute sense of professionalism and confidentiality
Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel)
Intermediate level of proficiency with Microsoft Excel, Word and Access
Capability of working in a fast-pace environment, flexibility with assignments and the ability to adapt in a changing environment
Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions).
Must not appear on any state/federal debarment or exclusion lists.
Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.

Nice To Haves

Bachelor’s degree, or an equivalent level of competence obtained through experience, education and/or training, may be required for some specific roles
Medical Coder certification is a plus
Experience with Commercial healthcare contracts and Reimbursement models (e.g. Medicare, Medicaid, & Commercial Insurance), is required
LTC (Long Term Care) Caseworker or Nursing Home technical and administrative skills preferred
Understanding of NAMI, Diversion/Deduction Calculations, Spenddown, and Estate Recovery preferred
Working knowledge of coordination of benefits and medical claims processing
Knowledge of insurance programs, particularly the coverage and Medicaid payment rules preferred
Experience with EHRs and billing software such as PointClickCare, SigmaCare or MatrixCare

Responsibilities

Conducts Medicaid claim audit reviews and determines if claims are appropriately paid in accordance with benefits, contracts and edits, includes review of specific coding and billing guidelines
Documents findings within audit tracking system and maintains thorough and objective documentation of findings
Investigates, researches, and analyzes claims data, applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive or inaccurate billing activity
Creates narrative rationale to correspond with audit determinations
As needed, supports findings during the appeals process
Serves as a claims payment resource; provides claims payment expertise, and claims payment guidance to the team
Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse
Monitors, tracks and reports on all work conducted
Consults with our clients, physicians, other claims payment resources and contractors as necessary
Maintains current knowledge of changes in technology, practice and regulatory issues that may affect our clients
Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives
As needed, assists with quality assurance functions, development of medical review guidelines and training
Identifies and recommends opportunities for cost savings and improving outcomes
Attends conference calls and meetings as requested
Performs other duties as assigned

Benefits

Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually.

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