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

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Healthcare Audit Recovery QA Analyst, Sr. (Data Mining)
Job Code:2022-50-R-065
Location:United States - Remote
Status:Regular Full Time

The Sr. Healthcare Audit Recovery QA Analyst is responsible for conducting quality review of commercial data mining audit work completed  by Data Mining team (Recovery Analysts, COB Analysts, Exploratory Analysts, etc.) to ensure the accuracy of claims payment determinations for our clients, as well as provide valuable insights for continuous improvement and training enhancement opportunities. .  Communicates and supports the identification of additional audit opportunities and participates in development of ideas as necessary. Able to contribute to resolution of more complex issues or client requirements and may support training and guidance to other Audit Recovery team members. .


• Conducts quality reviews on claim audit reviews completed by Commercial Data Mining Recovery Analysts 

• Documents quality review results and maintains thorough and objective documentation of findings in established QA logs and routes record appropriately within audit tracking system based upon QA review resulted in concurrence with Analyst review or identified corrections required. 

• Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of medical or pharmacy policy to 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 QA findings

• As needed, supports findings during the appeals process

• Serves as a senior claim payment resource; provides claims payment expertise, and claims payment guidance to the team

• Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse

• Provides QA log to Recovery Analysts (weekly and/or other frequency as required by management)

• Monitors, tracks, and reports on all work conducted

• Prepares QA 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 our clients, physicians, other claims payment resources and contractors as necessary

• Maintains current in-depth knowledge of changes in technology, practice and regulatory issues that may affect our clients

• Proactively contributes to process improvement activities and sets positive example for group participation and takes ownership in improvement initiatives

• Actively contributes to the development of medical review guidelines, coding guidelines, and training

• Proactively identifies and recommends opportunities for cost savings and improving outcomes

• Serves as positive role model and example for other Audit Recovery and QA Analysts

• May support training and guidance to other  Analysts in the department.

• Updates and maintains training documentation

• Attends conference calls and meetings as requested

• Complies with company policies, processes, and procedures

• 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

• Demonstrates Performant core values in performance of job duties and all interactions

• Performs other duties as assigned

*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:
• Strong working knowledge of coordination of benefits and medical claims processing

• Depth of knowledge of insurance programs, particularly the coverage and payment rules

• Demonstrated ability to apply breadth and depth of applicable business and industry knowledge to developing approaches to customer audit opportunities as well as continuous improvement initiatives

• 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. 

• Ability to be flexible and seizes the opportunity to cross train

• Ability to maintain high quality work while meeting deadlines and performance metrics

• Excellent organizational, interpersonal and communication skills with proven ability to provide constructive review feedback that supports individual and team continuous improvement. 

• Demonstrated ability to resolve complex problems 

• Ability to serve as a positive role model to more junior staff members

• Demonstrated ability to train and support team members with less experience with positive interaction and results

• Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings

• Must be able to manage multiple assignments effectively, create documentation outlining findings, QA review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.

• Acute sense of professionalism and confidentiality

• Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel)

• Intermediate level of proficiency with Microsoft Excel, Word, and Access

• Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment

Additional Requirements:

• Ability to obtain and maintain client required clearances 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:

**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements) until at which time staff may be notified and required to work from a Performant office location on an ad-hoc or periodic basis.

Basic office equipment required to perform remote work is provided by the company.

• Job is performed in a standard busy 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:
• Bachelor’s degree or an equivalent level of competence obtained through experience, education and/or training.

• Certified coder is a plus, but not a requirement

• 8+ years progressive experience in healthcare industry involving claims with demonstrated competency utilizing and quickly adapting to a variety of claim processing systems (commercial applications or proprietary systems)

• 5+ years of experience preferably in progressive audit roles

• 2+ years in role with responsibility for conducting quality review of audit work performed by others (QA function, supervisory role, etc.)

• 5+ years working with health care claims demonstrating expertise in, ICD-9/ICD-10 coding, HCPS/CPT-4 coding, and MS-DRG including medical billing experience for an Insurance Company or hospital Medical coding experience

Other Requirements:

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 clearances (as applicable).

• 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.
Employment VISA Sponsorship is not available for this position

Job Profile is subject to change at any time.

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.