Medical Review Audit Supervisor

ABOUT PERFORMANT:

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all.

If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

ABOUT THE OPPORTUNITY:

Hiring Range: $78,500 - $93,000

The Medical Review Audit Supervisor - Clinical RN (Commercial Home Health) leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Supervisor will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.
 

Key Responsibilities to include:

• Regularly performs limited volume of clinical audits to maintain subject matter expertise, and additionally as needed to support business needs.

• Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.

• Contributes to the resolution of quality review rebuttals.

• May perform appeals review/activity to supplement Appeals team, based upon business need.

• Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.

• Effectively ensures adherence to medical review guidelines and training requirements of staff.

• Supports audit management and segment specialists with activities for new concept implementation

• Supports management with needs assessments and capacity planning

• Monitor and manage inventory of assigned business to ensure timelines are met. 

• Use data, reports and experience to proactively identify potential backlogs and align resources to meet business needs and SLAs.

• Oversee and review audit determinations to ensure consistency in decision-making.

• Collaborate with other departments to resolve operational problems.

• Proactively monitors and in alignment with applicable management ensures activity required to meet team staffing levels necessary to achieve business objectives.

• Provides support as needed to ensure auditors are equipped with tools and resources required to perform audits.

• Supervise daily activities of clinical audit staff that may include both salaried exempt and hourly employees.

• Provide audit guidance to medical review staff; identify trends and present solutions.

• Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff.

• Manages team Time and Attendance (time off/use of accruals, attendance, attendance points and timecards for hourly staff, etc.) in accordance with applicable policies and procedures.

• Collaborates with The People Team for applicable corrective action as applicable.

• Complete and conduct performance reviews for assigned staff.

• Conduct team meetings with direct reports on a regular basis.

• Provide leadership to team members, provide solutions, and resolve conflicts.

• Escalate to management and collaborate with HR as applicable to bring appropriate solutions to employee matters.

• Provide reporting and updates to management as required and appropriate for operational and staff activity and results.

• Participates in and contributes to applicable department meetings.

• 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 3rd party/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.

• Identify needs and ensure team receives necessary training.

• 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 for self and team 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.

Knowledge, Skills and Abilities Needed:

• Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.

• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding. 

• Proficiency with MCS 1500/UB 04 forms

• Working knowledge of encoder

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.

• Proven ability to review, analyze, and research medical billing, documentation, and coding issues

• Reimbursement policy and/or claims software analyst experience

• Familiarity with interpreting electronic medical records (EHR)

• Willing and able to lead by example, communicate ideas, take initiative and drive the team to achieve organizational goals.

• Experience in developing, documenting and implementing process and procedures.

• Experience in inventory management, resource planning and report generation.

• Skill in analyzing information, identifying trends and presenting solutions.

• Understands inventory management objectives, activities, and key drivers in achieving operational goals.

• Demonstrated ability to consistently apply sound judgment and good effective decision making.

• Excellent 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.

• Demonstrated ability to successfully develop, lead, and motivate a team to high performance; effectively provides constructive feedback and coaching for successful outcomes.

• 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 positive role model, and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.

Required and Preferred Qualifications:

• Current active unrestricted Nursing license in good standing required.  Not currently sanctioned or excluded from the Medicare program by OIG, is also required.

• Medical coding certification is a plus.

• 3+ years diverse 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. Those who have less than 5 years experience may be considered based upon demonstrated skills and/or formal training and other relevant experiences

• 3+ years relevant supervisory or leadership experience in similar business environment, preferred.  Experience managing remote staff is a plus.

• Some Supervisory experience may be required for certain Supervisor roles.

• Prior experience in payer edit development, and/or reimbursement policy experience a plus.

WHAT WE OFFER:

Performant offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, disability coverage options, life insurance coverage, 401(k) savings plans, paid family/parental leave, 11 paid holidays per year, as well as sick time and vacation time off annually. For more information about our benefits package, please refer to our benefits page on our website or ask your Talent Acquisition contact during an interview.

Physical Requirements & Additional Notices:

If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required.  Proof of such may be required prior to an offer being made.  It is the Employee’s responsibility to maintain this Internet access at their home office location.

The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.

• Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone 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 computer mouse.

• Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).

• Regularly sit/stand 8 or more hours per day.

• Occasionally lift/carry/push/pull up to 10lbs.

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 other clearances (as applicable). As such, the following requirements will or may apply to this position:

• Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions).   Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.

• Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.

• Must complete the Performant Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.

• Other requirements may apply.

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.

Performant is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Performant will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Performant’s Human Resources team to discuss further.

Our diversity makes Performant unique and strengthens us as an organization to help us better serve our clients. Performant 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.

THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED