RAC Manager

Prime Healthcare•Ontario, CA

22d•Onsite

About The Position

The RAC Manager serves as the primary contact and representative handling the data/documentation requests received based on the Government audits and manage the appeals process as part of the denial management. Is knowledgeable in the specific functions of the clerical positions and serves as a resource for co-workers. Is responsible for maintaining integrity of tracking Government review audits (RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG and M-Cal), and others as they are created. Working with the Supervisor(s), a RAC manager functions as a subject matter expert (SME) for the appeals process and takes an active role in managing the process and coordinating with the RAC team, Corporate Utilization Review and Clinical appeals team. Provides supervision and direction for Medicare and Medicaid Appeals process along with analysis, resolution, monitoring & reporting of clinical denials. Facilitates peer to-peer following appeals submission for Fair Hearing for Medicaid audits. Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials. Reviews and determines appropriate strategy in response to reimbursement denials. Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration / CMO wherever applicable. In tandem with the Training Supervisor keeps abreast with the ongoing education/training to stay current with emerging industry trends on denials management. Performs ongoing audits; to monitor ADR requests and appeal/denial process and develops process improvement plans for identified deficiencies. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Performs other duties as assigned.

Requirements

Master’s in healthcare with one year experience in denial management.

Nice To Haves

ECFMG Certification
Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes.
Ability to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare disciplines.
Program and database development a plus
1+ year of clinical experience in acute care setting preferred.
Excellent written and verbal communication skills.
Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

Responsibilities

Serves as the primary contact and representative handling data/documentation requests received based on Government audits.
Manages the appeals process as part of denial management.
Maintains integrity of tracking Government review audits (RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG and M-Cal), and others as they are created.
Functions as a subject matter expert (SME) for the appeals process and takes an active role in managing the process and coordinating with the RAC team, Corporate Utilization Review and Clinical appeals team.
Provides supervision and direction for Medicare and Medicaid Appeals process along with analysis, resolution, monitoring & reporting of clinical denials.
Facilitates peer-to-peer following appeals submission for Fair Hearing for Medicaid audits.
Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials.
Reviews and determines appropriate strategy in response to reimbursement denials.
Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration / CMO wherever applicable.
Keeps abreast with the ongoing education/training to stay current with emerging industry trends on denials management.
Performs ongoing audits to monitor ADR requests and appeal/denial process.
Develops process improvement plans for identified deficiencies.
Able to work independently and use sound judgment.
Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
Performs other duties as assigned.