This position develops, interprets, and implements operational requirements for the Centers for Medicare & Medicaid Services' (CMS) Recovery Audit Contractor (RAC) program and has accountability for daily management, monitoring, and direction of RAC activities. This position provides financial data and analysis for internal and external reporting, ensures the hospital is prepared for RAC audits, responds to audit requests, challenges questionable determinations, and files timely appeals.

Essential Duties and Job Responsibilities

• Coordinates, initiates, monitors, and responds to all audit requests/demands.
• Initiates and monitors the appeal processes in a timely manner.
• Reviewing records for payor, RAC, regulatory denials/appeals, and downgrades by providing in depth coding review, audit findings and appeal strategies to the System Coding Leadership.
• Performs research, gathers financial data, and conducts focused audits on Medicare and Medicaid billing to analyze, summarize, prepare reports, and make recommendations.
• Coordinates with facility subject matter experts when necessary.
• Uses data or maintains database to track information including but not limited to trends regarding Medicare and Medicaid billing practice both within and outside of the hospital.
• Manages internal and external billing audit communications for all audit-related correspondence.
• Continuously evaluates and improves processes in preparation for audit requests and in response to audit findings.
• Assists interdisciplinary teams in identifying and prioritizing areas of process improvement and develop/implement processes and tools to mitigate risk.

Requirements & Qualifications:

Minimum Qualifications

• Must have 2-3 years of revenue cycle experience.
• Minimum three (3) or more years of experience in coding, billing, charge documentation, charge audit, or charge capture activities.
• Experience with coding, and auditing for physician practices is required. RHC experience preferred.
• Knowledge of Medicare reimbursement/payment policies, CMS CLAIMS Manual, audit reviews and analysis, medical terminology, and coding (ICD-9, CPT, etc.).
• Must possess strong organizational skills with a high level of accuracy and attention to detail.
• Must possess strong investigative, analytical, and critical thinking skills.
• Maintain confidentiality of all resident care information in accordance with HIPAA guidelines.

Avamere Living is an Equal Opportunity Employer and participates in E-Verify.