Project Mgr. RAC

The RAC Project Manager performs activities related to the coordination and management of the Medicare RAC Program involving audit defense and claims appeals. Works closely with Case Management staff for determination of medical necessity status. Monitors processes and implements procedures as needed to ensure compliance with federal guidelines involving reimbursement for services performed. Acts as a resource to provide board level reports of program status related to job related functions.

Required Skills:

• Knowledge of Medicare RAC program, audit defense and claims appeals; medical necessity status determinations; EMTALA, Never Events, HACs, or any other patient care regulatory elements.
• Knowledge base in medical terminology, healthcare coding processes including CPT4, HCPCS, ICD-9
• Knowledge of Medicaid and Medicare, HIPAA, TJC regulations, and healthcare laws and regulations.
• Knowledge and ability to interpret government regulations, medical documentation,
• Knowledge and ability to identify fraud, abuse, and penalties for documentation and coding violations based on governmental guidelines.
• Knowledge and ability to apply strong analytical skills, data management and operational process, and computer skills involved in the preparation of reports and presentations.
• Knowledge of complexities of an Academic Medical Center. Involves others appropriately in consultations and decisions.
• Ability to operate successfully in a constantly changing, fast-paced environment.
• Ability to apply clinical expertise to review and audit medical records.
• Ability to apply excellent interpersonal communication and negotiation skills.
• Ability to apply written and oral communication skills.
• Ability to work with people of all social, economic, and cultural backgrounds. Exemplifies an approachable style that elicits open communication with Associates, Management staff, and Physicians. Strong interpersonal skills demonstrating the ability to listen effectively.
• Ability to be flexible, open-minded and adaptable to change.
• Ability to apply strong organizational and time management skills to multi-task in a fast paced environment and prioritize tasks and role components.
• Ability to and coordinate with different departments and entities simultaneously in order to carry out auditing function to meet deadlines and goals.
• Ability to work independently and exercise sound judgment in interactions with members of the workforce, contracted vendors, and patients/families. Ability to maintain a high degree of credibility, independence, integrity, confidentiality and trust required.
• Ability to develop partnerships, teamwork and good working relationships and maintain an open, participative communication style.
• Bilingual English/Spanish preferred, culturally sensitive.

Required Experience:

Work Experience:

Three years of experience in healthcare project or program management required. Experience in case management, coding, auditing, healthcare fraud investigation, and clinical documentation preferred.

License/Registration/Certification

RN License: preferred;

Certified Case Manager: (CCM), Certified Professional Medical Auditor: (CPMA), or Certified Medical Audit Specialist: (CMAS) obtained within two years of accepting position.

Education/Training

Bachelors degree: required; preferably in Business, Medical Records Technology, Health Services Administration, Nursing or related field. Masters degree: preferred.