Performant Corporation is an Equal Opportunity Employer (Minorities/Females/Disabled/Veterans).

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Medical Review Coding Appeals Auditor (Outpatient)
Job Code:2022-50-R-019
Location:United States - Remote
Status:Regular Full Time
  
Responsibilities:
The Medical Review Coding Appeals Auditor (Outpatient) is responsible for conducting Appeals reviews of new evidence presented by auditee’s, disputing all or part of the findings from medical review audit work completed by the medical review coding audit team members, Communicates and supports the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools.   Responsible for performing some audit activity and consistently achieves or exceeds productivity goals and quality standards. Serves as subject matter expert, provides supplemental escalation support, and may perform special project activity as needed.


Duties
•Performs limited volume of outpatient coding reviews on medical records to maintain subject matter expertise, and additionally as needed to support business needs.
•Conducts Appeals reviews on medical review audit work completed by the medical review coding audit team members, as new evidence is presented by auditees
•Objectively and accurately documents Appeals results in accordance with department quality policies and procedures, scoring and reporting all Appeals results and routes record appropriately within audit platform based upon how the Appeal review resulted in concurrence with audit finding or identified corrections required. 
•Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings. 
•Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings
•Contributes to the continuous improvement feedback process and suggests or makes any edits, documentation, next steps, and reporting as may be necessary in accordance with department process and audit leadership direction.
•May perform primary audit activity as assigned by management
•Monitors, tracks, and reports on all work conducted in accordance with Appeals process and management direction. 
•May prepare reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept based/trended, or other characteristic that will provide valuable business insights.
•Consults with internal resources as necessary.
•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.
•Participates in and contributes to applicable department meetings.
•Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position.
•Proactively contributes to continuous improvement of activities and sets positive example 
•Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.
•May support training material/tools and best practices development.
•May identify/make recommendations to management for supplemental team/concept type training.
•May 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 as necessary.
•Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law.
•Performs job duties with high level of professionalism and maintains confidentiality
•Perform other incidental and related duties as required and assigned to meet business needs.


*Note - All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As 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 times.  Violations 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:

•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.
•Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10 
•Proficiency with MCS 1500/UB 04 forms
•Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations.
•Working knowledge of encoder
•Proven ability to review, analyze, and research 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.
•Independent, out-of-the-box thinker; Performs successfully against work given in the form of objectives and projects; leads by example.
•Understands processes, procedures, and workflow; and demonstrated ability to identify areas of opportunity
•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 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 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
•Ability to obtain and maintain client required clearances, if applicable, as well as pass company regular background and/or drug screening.
•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:
•Job is in a busy standard  is performed in an office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or headset provided by the Company for 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 mouse.
•Reads and comprehends information in electronic (computer) or paper form (written/printed). 
•Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.
•Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.
•Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment with account holders, may dial manually when need or use dialer system; headset is also provided.
•Occasionally lift/carry/push/pull up to 10lbs.
 
Education and Experience:
•Current certification as a CPC, CPC-H, CPC-P, RHIA, RHIT, CCS, or CCS-P
•Not currently sanctioned or excluded from the Medicare program by OIG
•3+ years of direct experience in medical chart review for all provider/claim types for outpatient
•5+ years relevant auditing experience in a provider or payer environment demonstrating breadth and depth of knowledge/skills for the position. (less than 5 yrs. may be considered for internal candidates based upon demonstrated skills and results).
•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 preferred.

Other Requirements
•Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.
•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 contractor. Certain 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 employer. All 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. 

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