Job details
Job type full-time
Full job description
The medical review documentation audit supervisor leverages their knowledge of healthcare insurance programs, medical claim audit, billing and documentation expertise, as well as experience leading others to manage staff and operational results for a remote team of non-exempt staff conducting review of post and pre-payment medical claim records for documentation and billing accuracy for specific items (e.gDme, drug, home health) on behalf of government and commercial payersResponsible leveraging first-hand experience and knowledge of claims auditing, for supporting management with strategy activities such as needs assessments, capacity planning, preparing staffing models, ensuring required staffing levels, cost/benefit analysis, and establishing productivity and quality standards.
Regularly performs limited volume of claim reviews on medical records to maintain subject matter expertise, and additionally as needed to support business needs.
Performs audit quality assurance reviews to supplement qa team activity as necessary based upon business need or special projects.
Contributes to the resolution of quality review rebuttals.
Performs appeals review/activity to supplement appeals team based upon business need.
Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company`s profitability.
Effectively contributes to the development of medical review guidelines and training.
Supports audit management and segment specialists with activities for new concept implementation, maintenance of medical review guidelines for existing concepts.
Use data, reports, and experience to proactively identify potential backlogs and align resources to meet business needs and slas.
Oversee and review audit determinations in order to ensure consistency in decision-making.
Collaborate with other departments to resolve operational problems.
Proactively monitors and in alignment with applicable management ensures activity required to meet team staffing levels necessary for assigned business segment objectives.
Provides support as needed to ensure auditors are equipped with tools and resources required to perform audits.
Supervise daily activities of audit staff members.
Provide audit guidance to medical review staff; identify trends and present solutions.
Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff.
Manages team time and attendance (time off/use of accruals, attendance, attendance points and timecards for hourly staff, etc.) in accordance with applicable policies and procedures.
Collaborates with hr for applicable corrective action as applicable.
Complete and conduct performance reviews for assigned staff.
Conduct team meetings with direct reports on a regular basis.
Provide leadership to team members, provide solutions, and resolve conflicts.
Escalate to management and collaborate with hr as applicable to bring appropriate solutions to employee matters.
Provide reporting and updates to management as required and appropriate for operational and staff activity and results.
Participates in and contributes to applicable department meetings.
May participate to client-facing meetings; research and analyze issues; present findings and solutions; and/or provider training.
May support management with activities to monitor inventory and activity of 3rdparty/subcontractors.
Become subject matter expert for assigned business segment(s).
Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.
May support training material/tools and best practices development.
Identify needs and ensure team receives necessary training.
Support training activities for new audit staff or provide supplemental training for existing staff as needed.
Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.
Receives feedback and adjusts work priority for self and team as necessary.
Leads by example and conducts work in accordance with company policies, government regulations and law.
Perform other incidental and related duties as required and assigned to meet business needs.
Notes:
All employees and contractors for performant financial may and/or will have access to sensitive, proprietary, confidential and/or public dataAs such, all employees and contractors will have ownership and responsibility to report any violations to the confidentiality and integrity of sensitive, proprietary, confidential and/or public data at all timesViolations to performant’s policy related to the confidentiality or integrity of data may be subject to disciplinary actions up to and including termination.
Required skills and knowledge:
Strong knowledge of medical billing, documentation requirements and an understanding cms, medicaid and/or commercial insurance programs, particularly the coverage and payment rules and regulations.
Thorough working knowledge of cpt/hcpcs/icd-9/icd-10/ms-drg coding.
Proficient in the use of mcs 1500/ub 04 forms
Working knowledge of encoder
Proven ability to review, analyze, and research medical billing, documentation, and coding issues
Reimbursement policy and/or claims software analyst experience.
Familiarity with interpreting electronic medical records (ehr).
Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing.
Willing and able to lead, communicate ideas, take initiative and drive the team to achieve organizational goals.
Experience in developing, documenting and implementing process and procedures.
Experience in inventory management, resource planning and report generation.
Skill in analyzing information, identifying trends and presenting solutions.
Understands inventory management objectives, activities, and key drivers in achieving operational goals.
Demonstrated ability to consistently apply sound judgment and good effective decision making.
Excellent communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.
Demonstrated ability to collaborate effectively in a variety of settings and topics.
Excellent editing and proofreading skills.
Demonstrated ability to successfully develop, lead, and motivate a team to high performance; effectively provides constructive feedback and coaching for successful outcomes.
Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.
Excellent time management and delivers results balancing multiple priorities.
Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.
Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.
Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.
Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.
Ability to create documentation outlining findings and/or documenting suggestions.
Strong general technical skills, including, but not limited to desktop and ms office applications (intermediate excel skills), application reporting tools, and case management system/tools to review and document findings.
Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.
Ability to be flexible and thrive in a high pace environment with changing priorities.
Adaptable to applying skills to diverse operational activities to support business needs.
Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.
Serves as positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.
Limited travel may be required
Completion of teleworker agreement upon hire, and adherence to the agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with hipaa, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.
Physical requirements
**note: must be able to meet requirements for and perform work assignments in accordance with company policies and expectations on a home remote basis (and must meet performant remote-worker requirements) until at which time staff will be notified and required to work from a performant office locationBasic office equipment required to perform remote work is provided by the company.
Performs duties in a busy standard office environment with moderate noise level(or home-based telework environment in accordance with company policies and procedures).
Sits or stands at a desk, reaching as needed to use office equipment.
Makes and returns calls using an office phone system or company issued cellular phone.
Views a computer monitor, types on a keyboard, and uses a mouse.
Reads and comprehends information in electronic (computer) or paper form (written/printed).
Types frequently, but not constantly, using a keyboard and mouse.
Occasionally lifts/carries/pushes/pulls up to 10 pounds.
Travel as required to meet business needs.
Education and experience:
Current unrestricted nursing license in good standing.
Current certification as a cpc, cpc-h, cpc-p, rhia, rhit, ccs, or ccs-p desired but not required.
Not currently sanctioned or excluded from the medicare program by oig
3+ years diverse nursing experience providing direct care in an inpatient or outpatient setting.
2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company.
5+ years in health care claims that demonstrates expertise in icd-9/icd-10 coding, hcps/cpt coding, drg and medical billing experience for an insurance company or hospital required.
(less than 5 yrsMay be considered for internal candidates based upon demonstrated skills and results)
3+ years relevant supervisory or leadership experience in similar business environment (preferably experience overseeing remote staff).
Prior experience in payer edit development, and/or reimbursement policy experience a plus.
Other requirements
Must submit to and pass pre-hire background check, as well as additional checks throughout employment
Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.
Must submit to and pass drug screen pre-employment (and throughout employment).
Performant is a government contractorCertain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the company.
Visa sponsorship is not available.
Job profile is subject to change at any time.
Eeo
Performant financial corporation is an equal opportunity employer.
Performant financial corporation is committed to creating a diverse environment and is proud to be an equal opportunity employerAll qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
No agency submissions without performant authorized agency agreement and approved performant job order
