Medical Review Manager: Performant Financial Corporation

Medical Review Manager

The Centers of Medicare and Medicaid (CMS) awarded the Recovery Audit Contract (RAC) to DCS Healthcare for Region A, representing the North Eastern region of the U.S. and one of the four regions for which CMS contracted.

DCS Healthcare is seeking an experienced medical review manager with a strong background in Medicare coding, billing and the appropriate application and implementation of Medicare policy with respect to auditing claims. The Medical Review Manager plays an important role in the RAC contract.

The successful candidate will have an excellent understanding of Medicare policy and have the ability to ensure that audit staff performs audits in a manner consistent with review guidelines. Additionally the candidate must have demonstrated strong operational and management skills, and possess the ability to quickly build and manage teams in a fast paced, multi-location environment.

Responsibilities include:

• Involvement and oversight at all levels of the audit process:

o Ensure that all Medicare laws, rules, and regulations are applied appropriately.

o Participate in the identification and submission of Major Issues to CMS.

o Participate in establishing edit parameters.

o Collaborate in writing and oversee implementation of medical review guidelines.

o Coordinate with medical specialty consultants.

o Ensure quality and continuous improvement.

o Support the discussion and appeals process.

• Assist in the development and training of the review team and customer service staff (CSS).
• Participate in provider outreach and communication (as needed).
• Cooperatively work with Medicare Administrative Contractors (MACs) by indentifying and implementing process improvements
• Interact with providers during the discussion period.
• Collaborate and oversee policy and procedure development and implementation pertinent to the RAC review process.
• Keep apprised of changes to Medicare policy, changes in medical practice and other regulatory issues that may affect the RAC contract.
• Oversee work of subcontractor auditors as required.
• Develop and implement a quality assurance program for internal and subcontracted auditors.
• Interface with and support the Medical Director.
• Hire appropriate audit staff based on issues to be audited.

Requirements:

• 7 to 10 years of healthcare experience in the areas of medical billing, medical claim adjudication/payments, and/or medical claims recovery auditing
• 5 to 7 years progressive experience managing auditing, billing, and/or claims adjudication/review staff
• Knowledgeable of standard inpatient and outpatient coding methodlogies
• Knowledge of healthcare claim adjudication procedures and standards
• Must be a good problem solver and have an ability to make decisions and implement them in a timely manner
• Proficient in the use of standard “office suite” of products including
• Must have an ability to present ideas clearly and communicate well
• Must be team oriented
• RN (BSN preferred) with nationally recognized coding certification