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

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Medical Review Audit Lead - Clinical
Job Code:2021-50-4-024
Location:San Angelo, TX
Status:Regular Full Time
  
Responsibilities:

The Medical Review Audit Lead – Clinical leverages their nursing background and clinical review experience to provide support to assigned Medical Review Manager(s) with inventory management, operational monitoring and reporting, resource planning, continuous improvement initiatives, and other functions to maximize operational results. Responsible for performing audit activity and consistently achieves or exceeds productivity goals and quality standards. Serves as  subject matter expert, provides supplemental escalation support, and may perform QA and Appeals activity as needed.

•Performs clinical audits and consistently achieves or exceeds productivity goals and quality standards.  Supports additional activity as needed to support business needs. 
•Serves as secondary resource for the clinical auditors for claim specific questions, industry standards and escalation of  issues.
•May perform audit quality assurance review and activities to supplement QA team based upon business need or special projects.
•May support appeals review/activity to supplement Appeals team based upon business need.
•Supports audit management and segment specialists with activities for new concept implementation, maintenance of medical review guidelines for existing concepts, which may include, but not limited to, support with questions and training.
•Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.
•Makes staff inventory assignments and changes to meet business needs and audit timelines.
•Monitors and provides inventory and staff operational reporting for assigned manager’s teams and scope of business.
•Proactively identifies potential issues and deficiencies; performs research and analysis to identify root cause; and make recommendations. 
•Supports manager(s) with planning and implementing operational changes and other projects and initiatives to achieve business goals. 
•Assists with activities to supplement or reinforce training as may be required to optimize operational results.
•Assists management in disseminating information to the teams in a timely manner and ensuring understanding and application.
•Participates in and contributes to applicable department meetings.
•May contribute to staffing related activities (such as interview, onboarding preparation, and ramp-up activities). 
•May participate to client-facing meetings; research and analyze issues; present findings and solutions; and/or provider training.
•May support management with activities to monitor inventory and activity of 3rdparty/subcontractors. 

•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.
•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.
•Leads by example and conducts work in accordance with company policies, government regulations and law.
•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:

•Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding.  
•Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.
•Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.
•Strong knowledge of medical documentation requirements
•Independent, out-of-the-box thinker; Performs successfully against work given in the form of objectives and projects; leads by example.
•Understand processes, procedures and workflow; able to identify areas of opportunity.
•Demonstrated ability to consistently apply sound judgment and good effective decision making.
•Understands inventory management 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 technical 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. 
 
•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). Basic office equipment required to perform remote work is provided by the company.
•Performs duties in a busy standard office environment with moderate noise level. (or home-based Telework environment in accordance with Company policies and procedures).
•Sits or stands at a desk, reaching as needed to use office equipment.
•Makes and returns calls using an office phone system or company issued cellular phone.
•Views a computer monitor, types on a keyboard, and uses a mouse.
•Reads and comprehends information in electronic (computer) or paper form (written/printed).
•Types frequently, but not constantly, using a keyboard and mouse.
•Occasionally lifts/carries/pushes/pulls up to 10 pounds.
•Travel as required to meet business needs.
 
 

Education and Experience:

•Current active unrestricted Nursing license in good standing required (RN required for government contract focused positions)
•Not currently sanctioned or excluded from the Medicare program by OIG
•Medical coding certification preferred.

•3+ years diversified nursing experience providing direct care in an inpatient or outpatient setting.
•2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company.  
•5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
(less than 5 yrs. may be considered for internal candidates based upon demonstrated skills and results)
•Prior lead or supervisory experience in relevant business environment Desired (preferably experience in remote setting).
 

Other Requirements

•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. 

NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZED AGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDER