RAC Manager

About the Role

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states, providing over 3.0 million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity.

Responsibilities

• Serve as the primary contact and representative handling data/documentation requests received based on Government audits and manage the appeals process as part of denial management.
• Act as a resource for co-workers, knowledgeable in the specific functions of clerical positions.
• Maintain integrity of tracking Government review audits (RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG, M-Cal, and others as they are created).
• Function as a subject matter expert (SME) for the appeals process, managing and coordinating with the RAC team, Corporate Utilization Review, and Clinical appeals team.
• Provide supervision and direction for Medicare and Medicaid Appeals process, including analysis, resolution, monitoring, and reporting of clinical denials.
• Facilitate peer-to-peer follow-up following appeals submission for Fair Hearing for Medicaid audits.
• Serve as a liaison between Case Management, Business Office, and Coding teams to ensure timely reporting, tracking, and follow-up of denials.
• Review and determine appropriate strategy in response to reimbursement denials.
• Coordinate data analytics to determine denial trends and reasons, reviewing with administration/CMO where applicable.
• Stay current with emerging industry trends on denials management through ongoing education/training in tandem with the Training Supervisor.
• Perform ongoing audits to monitor ADR requests and appeal/denial processes, developing process improvement plans for identified deficiencies.
• Work independently and use sound judgment.
• Apply knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for continuity of treatment.
• Perform other duties as assigned.

Requirements

• Master’s in healthcare with one year of experience in denial management.

Qualifications

• Preferred Qualifications:
  • ECFMG Certification and/or Bachelor’s or higher from a US-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 is a plus.
  • 1+ year of clinical experience in an acute care setting preferred.
  • Excellent written and verbal communication skills.
  • Excellent critical thinking skills.
  • Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff, and hospital management staff.

Benefits

Prime Healthcare offers a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to:

• Paid time off
• 401K retirement plan
• Medical, dental, and vision coverage
• Tuition reimbursement
• Many more voluntary benefit options

Benefits may vary based on employment status (full-time, part-time, per diem, or temporary).

Pay

A reasonable compensation estimate for this role is $71,760.00 to $94,619.20 on an annualized basis. The exact starting compensation will be determined at the time of hire, considering factors such as skillset, years of applicable experience, education, credentials, and licensure.

Schedule

• Full Time
• Day Shift