Medical Review Clinical Appeals Auditor - (RN) Government/Clinical Outpatient Focus

Knowledge, Skills and Abilities Needed: Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others. Must be able to manage multiple assignments effectively, create documentation outlining findings, Appeals review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members. Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding may be necessary. Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations, may be necessary. Experience with utilization management systems or clinical decision-making tools such as Millimen Care Guidelines (MCG) or InterQual. Working knowledge of encoder may be necessary. Reimbursement policy and/or claims software analyst experience may be necessary. Familiarity with interpreting electronic medical records (EHR) Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing. Demonstrated ability to consistently apply sound judgment and good effective decision making. Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals. Ability to efficiently and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions. Strong 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. 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 computer skills, including, but not limited to Desktop and MS Office applications (Intermediate-to-Advanced Excel Skills), application reporting tools, and case management system/tools to review and document findings. Advanced 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 a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams. Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment. Required and Preferred Qualifications Active unrestricted RN license in good standing and diversified nursing experience providing direct care in an inpatient or outpatient setting, is required. At least 5+ years relevant experience in a provider or payer environment demonstrating breadth and depth of auditing knowledge/skills for the position. Less than 5 years may be considered for internal candidates based upon demonstrated skills and results. Not currently sanctioned or excluded from the Medicare program by OIG. Must have strong technical aptitude and intermediate to advanced skills using Excel. One or more years of experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies and/or medical billing experience for an Insurance Company or hospital or other appropriate medical provider may be required. Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions. Prior experience in role with responsibility for conducting primary audit, utilization management or prior-authorization work, or review of audit work performed by others (QA function, appeals function, lead, supervisory role, etc.) Prior experience in payer edit development and/or reimbursement policy a plus. Prior experience working in remote setting is strongly preferred. Must be comfortable solving minor/intermediate technical issues, with or without immediate remote assistance. Physical Requirements & Additional Notices: If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee’s responsibility to maintain this Internet access at their home office location. The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary. Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse. Regularly reads and comprehends information in electronic (computer) or paper form (written/printed). Regularly sit/stand 8 or more hours per day. Occasionally lift/carry/push/pull up to 10lbs. Performant is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position: Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions. Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists. Must complete the Performant Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures. Other requirements may apply.

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