Project Mgr. RAC

About the Role

The RAC Project Manager coordinates and manages the Medicare RAC Program, focusing on audit defense and claims appeals. This role works closely with Case Management staff to determine medical necessity status, monitors processes, and implements procedures to ensure compliance with federal reimbursement guidelines. The position serves as a resource for board-level reports on program status.

Responsibilities

• Coordinate and manage activities related to the Medicare RAC Program, including audit defense and claims appeals.
• Collaborate with Case Management staff to determine medical necessity status of claims.
• Monitor and implement processes to ensure compliance with federal guidelines for reimbursement.
• Provide board-level reports on program status and related functions.
• Apply clinical expertise to review and audit medical records.
• Identify fraud, abuse, and penalties for documentation and coding violations based on governmental guidelines.
• Interpret government regulations, medical documentation, and healthcare laws.
• Develop and maintain strong analytical, data management, and operational processes for report preparation and presentations.
• Coordinate with multiple departments and entities to meet auditing deadlines and goals.
• Exercise sound judgment in interactions with workforce members, contracted vendors, and patients/families.

Requirements

• Three years of experience in healthcare project or program management.
• Experience in case management, coding, auditing, healthcare fraud investigation, or clinical documentation is preferred.
• Bachelor’s degree required; preferably in Business, Medical Records Technology, Health Services Administration, Nursing, or a related field.
• Master’s degree preferred.

Qualifications

• Knowledge of the Medicare RAC program, audit defense, and claims appeals.
• Understanding of medical necessity status determinations and patient care regulatory elements (e.g., EMTALA, Never Events, HACs).
• Proficiency in medical terminology and healthcare coding processes (CPT4, HCPCS, ICD-9/ICD-10).
• Knowledge of Medicaid, Medicare, HIPAA, TJC regulations, and healthcare laws.
• Ability to interpret government regulations and identify fraud, abuse, and penalties for documentation and coding violations.
• Strong analytical, data management, and operational process skills.
• Familiarity with the complexities of an Academic Medical Center.

Skills

• Excellent interpersonal, communication, and negotiation skills.
• Ability to work with diverse social, economic, and cultural backgrounds.
• Strong organizational and time management skills to multitask in a fast-paced environment.
• Ability to work independently, exercise sound judgment, and maintain confidentiality.
• Flexibility, adaptability, and openness to change.
• Ability to develop partnerships, foster teamwork, and maintain open communication.
• Bilingual (English/Spanish) preferred; culturally sensitive.

Preferred certifications: RN License, Certified Case Manager (CCM), Certified Professional Medical Auditor (CPMA), or Certified Medical Audit Specialist (CMAS).