Healthcare Services Segment Specialist (RAC/OIG Focus)

Performant • Plantation, FL

3d • $100,000 - $120,000 • Remote

About The Position

The Healthcare Services Segment Specialist applies specific subject matter expertise in Payment Integrity to support of audit business activity performing the following essential duties:

Requirements

• Demonstrates expertise (depth and breadth) of knowledge of payment integrity elements. Examples include: ICD-10-CM, ICD-10-PCS, CPT, HCPCS, or HIPPS coding and MS-DRG, APR-DRG, APC, APG, PDPM, or PDGM payment methodologies
• Strong people skills: ability to communicate with all levels within the organization, with diverse teams as well with external customers.
• Exceptional written and verbal communication skills.
• Strong attention to detail.
• Excellent critical thinking and analytical skills.
• Time management skills for managing multiple tasks simultaneously, while completing work within allocated time frames.
• Ability to work independently and in a remote environment.
• Strong Microsoft suite skills, such as – Excel, Word, Outlook and SharePoint.
• Minimum 8+ years of progressive experience in healthcare claim type subject matter specialty specific to the position.
• Bachelor's degree in related field or equivalent experience
• Registered Nurse or Certified Coder holding nationally recognized credentials (RHIA, RHIT, AHIMA, AAPC, etc.) required
• A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
• Progressive health care data analysis experience including gathering and documenting requirements for projects of diverse sizes.
• If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required . Proof of such may be required prior to an offer being made. It is the Employee’s responsibility to maintain this Internet access at their home office location.
• Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions).
• Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.
• Some positions may require the total absence of felony and/or misdemeanor convictions.
• 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.

Responsibilities

• Responsible and leads reviews, ensures updates of existing concepts based upon required periodic review cycle or as needed based upon client or regulatory changes (research, analysis, update rule documents, code lists and edits accordingly).
• Ensure training material updates (may develop or coordinate) as necessary for changes to existing concepts.
• Contributes to development of training materials and tools for new concepts.
• Conduct research, identify impact on existing concepts, and document accordingly for new concept development
• Interpret and apply client policy in existing concept review/updates
• Responsible for responding to client inquiries and providing support to client services with client presentations
• Ensure audit concepts are well formulated for Offerings (Data Mining vs Complex Audit; CMS vs Medicaid vs Commercial)
• Responsible for monitoring and providing statistical analysis to drive scoring and selection for new and existing audit concepts.
• Responsible for the monitoring of concept performance.
• Manage, progress, and track multiple tasks within multiple workflows for audit concept maintenance with high degree of accuracy and quality providing status reports and deliver results on-time.
• Responsible for QA management of all client concepts ensuring compliance with regulatory, coding, or citation changes and are applied to concepts timely.
• Stay informed of payment integrity policy and current trends.
• Provides oversight of SME team members to ensure on time project deliveries, cross train, and knowledge transfer, and maintain required quality and productivity standards.
• Performs other duties as assigned and required to meet business needs.

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.
• For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees