Project Mgr. RAC

Summary

The RAC Project Manager coordinates and manages the Medicare RAC Program, focusing on audit defense, claims appeals, and medical necessity determinations. This role involves close collaboration with Case Management staff and monitors processes to ensure compliance with federal guidelines.

Responsibilities

• Works closely with Case Management staff to determine medical necessity status.
• Maintains and implements procedures to ensure compliance with federal guidelines regarding reimbursement for services.
• Provides board-level reports on program status related to job responsibilities.

Requirements

• Knowledge of Medicare RAC program, audit defense, and claims appeals.
• Understanding of medical terminology and healthcare coding processes (CPT4, HCPCS, ICD-9).
• Comprehensive knowledge of Medicaid and Medicare, HIPAA, TJC regulations, and healthcare laws.
• Ability to interpret government regulations, analyze medical documentation, and identify fraud, abuse, and documentation/coding violations.
• Strong analytical, data management, and operational process skills.
• Proficiency in report and presentation preparation.
• Experience in an academic medical center setting.
• Ability to consult and make decisions with others.
• Flexibility, adaptability, and the ability to work in a fast-paced environment.
• Ability to review and audit medical records and apply clinical expertise.
• Excellent interpersonal communication and negotiation skills.
• Strong organizational and time management skills.
• Ability to coordinate with various departments and entities simultaneously.
• High degree of credibility, independence, integrity, confidentiality, and trust.
• Ability to develop partnerships, teamwork, and maintain open communication.
• Bilingual English/Spanish preferred, culturally sensitive.

Qualifications

• Bachelor's degree required; preferably in Business, Medical Records Technology, Health Services Administration, Nursing, or a related field.
• Masters degree preferred.
• Three years of experience in healthcare project or program management.
• Experience in case management, coding, auditing, healthcare fraud investigation, and clinical documentation preferred.
• RN license preferred; CCM, CPMA, or CMAS certification obtained within two years of accepting the position.