RAC Manager

Prime Healthcare Management Inc•Ontario, CA

50d•$71,760 - $94,619

About The Position

The RAC Manager serves as the primary contact for government audit data and documentation requests and manages the related appeals process as part of denial management. The role maintains the integrity of tracking government review audits, including RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG, and M-Cal, and acts as a subject matter expert on appeals. The manager coordinates with the RAC team, Corporate Utilization Review, and the Clinical Appeals team, while supervising and directing Medicare and Medicaid appeals and the analysis, resolution, monitoring, and reporting of clinical denials. The RAC Manager facilitates peer-to-peer reviews following appeals submissions for Medicaid audit fair hearings and liaises with Case Management, Business Office, and Coding teams to ensure timely reporting, tracking, and follow-up of denials. The role reviews reimbursement denials and determines appropriate response strategies, coordinates analytics on denial trends and causes, and works with the Training Supervisor to stay current on industry developments in denial management. The manager conducts ongoing audits of ADR requests and appeal/denial processes, develops improvement plans for identified deficiencies, works independently using sound judgment, and applies knowledge of applicable federal, state, and intermediary guidelines for inpatient acute care and lower levels of care. Other duties may be assigned.

Requirements

Master’s degree in healthcare.
One year of experience in denial management.
Able to work independently and use sound judgment.
Knowledge of federal, state, and intermediary guidelines related to inpatient acute care hospitalization and lower levels of care for continuity of treatment.

Nice To Haves

ECFMG certification and/or a bachelor’s or higher degree from a U.S.-based accredited institution in a Health and Human Services field.
Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes.
Ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other healthcare disciplines.
Program and database development experience.
At least one year of clinical experience in an acute care setting.
Excellent written and verbal communication skills.
Excellent critical thinking skills.
Excellent interpersonal skills for building effective partnerships with physicians, nursing staff, coding staff, and hospital management staff.

Responsibilities

Serve as the primary contact and representative for data and documentation requests arising from government audits.
Manage the appeals process as part of denial management and maintain accurate tracking of government review audits, including RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG, and M-Cal.
Serve as a subject matter expert for appeals and coordinate the appeals process with the RAC team, Corporate Utilization Review, and the Clinical Appeals team.
Supervise and direct Medicare and Medicaid appeals, including analysis, resolution, monitoring, and reporting of clinical denials.
Facilitate peer-to-peer reviews following appeals submissions for Medicaid audit fair hearings.
Liaise with Case Management, Business Office, and Coding teams to support timely reporting, tracking, and follow-up of denials.
Review reimbursement denials and determine appropriate response strategies.
Coordinate data analytics to identify denial trends and causes for review with administration or the CMO when applicable.
Work with the Training Supervisor to stay current with ongoing education and emerging industry trends in denial management.
Conduct ongoing audits of ADR requests and the appeals and denial process, and develop process improvement plans for identified deficiencies.
Perform other duties as assigned.