Medical Review Nurse – CMS RAC, Government Audits

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🕒 June 30

🐊 Florida – Remote

🐊 Florida – Remote

💵 $81k - $90k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Performant Healthcare, Inc.

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

Performant Healthcare, Inc. is a U. S. -based, technology-enabled payment integrity and recovery company that helps health plans and government payers identify improper payments, recoup funds, and reduce waste. Performant combines data analytics, audit expertise, and recovery/collections infrastructure to deliver services including inpatient and outpatient audits, post-acute/home care audits, third-party liability (TPL) identification, Medicare Secondary Payer (MSP) outreach, lockbox and OCR document processing, and end-to-end recovery management. The company emphasizes scalable, customizable solutions (Audit Advantage, Data Mining Advantage, MSP Advantage, TPL Advantage, Recovery Advantage) to control costs and improve payment accuracy for managed care organizations and government agencies, backed by more than 40 years of recovery experience.

📋 Description

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules • Document all findings referencing the appropriate policies and rules • Generate letters articulating audit findings • Supporting your findings during the appeals process if requested • Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse • Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits • Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients • Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members • Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines • Interface with and support the Medical Director and cross train in all clinical departments/areas • Other duties as required to meet business needs

🎯 Requirements

• Active unrestricted RN license in good standing, is required • Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting • One (1) or more years' experience performing medical records review • One (1) or more years' experience 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 • Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions

🏖️ Benefits

• medical • dental • vision • HSA/FSA options • life insurance coverage • 401(k) savings plans • family/parental leave • paid holidays • paid time off annually