Prime Healthcare

Acquires and reorganizes underperforming hospitals

RAC Manager

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeOntario, CA, USA$71.8k - $94.6k /yrIn-person

About the Job

Requirements

A Master's degree in healthcare and one year of experience in denial management are required.
Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes is preferred.
The ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other healthcare disciplines is preferred.
Program and database development experience is a plus.
At least one year of clinical experience in an acute care setting is preferred.
Excellent written and verbal communication skills are preferred.
Excellent critical thinking skills are preferred.
The ability to build effective partnering relationships with physicians, nursing staff, coding staff, and hospital management staff is preferred.

Responsibilities

Serve as the primary contact and representative for data and documentation requests arising from government audits, and manage the appeals process as part of denial management.
Maintain knowledge of clerical position functions and serve as a resource for co-workers.
Maintain the integrity of tracking government review audits, including RAC, MAC, CERT, OIG, pre- and post-probes, HSAG, and M-Cal audits, as well as other audit types as they are created.
Work with supervisors as a subject matter expert for the appeals process; actively manage the process and coordinate with the RAC team, Corporate Utilization Review, and the Clinical Appeals team.
Supervise and direct the Medicare and Medicaid appeals process, including analysis, resolution, monitoring, and reporting of clinical denials.
Facilitate peer-to-peer reviews following appeals submission for Medicaid fair hearings.
Liaise between Case Management, the Business Office, and Coding teams to ensure timely reporting, tracking, and follow-up of denials.
Review reimbursement denials and determine an appropriate response strategy.
Coordinate data analytics to identify denial trends and reasons for review with administration or the CMO when applicable.
Work with the Training Supervisor to stay current with ongoing education and training on emerging denial-management trends.
Perform ongoing audits to monitor ADR requests and the appeals and denial process, and develop process-improvement plans for identified deficiencies.
Work independently and use sound judgment.
Apply knowledge of federal, state, and intermediary guidelines related to inpatient acute-care hospitalization and lower levels of care for continuity of treatment.
Perform other duties as assigned.

Desired Qualifications

ECFMG certification and/or a Bachelor's degree or higher from a U.S.-based accredited institution in a Health and Human Services field is highly preferred.

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The RAC Manager serves as the primary contact and representative handling the data/documentation requests received based on the Government audits and manage the appeals process as part of the denial management. Is knowledgeable in the specific functions of the clerical positions and serves as a resource for co-workers. Is responsible for maintaining integrity of tracking Government review audits (RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG and M-Cal), and others as they are created. Working with the Supervisor(s), a RAC manager functions as a subject matter expert (SME) for the appeals process and takes an active role in managing the process and coordinating with the RAC team, Corporate Utilization Review and Clinical appeals team. Provides supervision and direction for Medicare and Medicaid Appeals process along with analysis, resolution, monitoring & reporting of clinical denials. Facilitates peer to-peer following appeals submission for Fair Hearing for Medicaid audits. Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials. Reviews and determines appropriate strategy in response to reimbursement denials. Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration / CMO wherever applicable. In tandem with the Training Supervisor keeps abreast with the ongoing education/training to stay current with emerging industry trends on denials management. Performs ongoing audits; to monitor ADR requests and appeal/denial process and develops process improvement plans for identified deficiencies. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Performs other duties as assigned.

Qualifications

Required qualifications:

Master’s in healthcare with one year experience in denial management.

Preferred qualifications:

ECFMG Certification And/or Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.

Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes; ability to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare disciplines; program and database development a plus

1+ year of clinical experience in acute care setting preferred.

Excellent written and verbal communication skills. Excellent critical thinking skills.

Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

Pay Transparency

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $71,760.00 to $94,619.20 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf

About the Company

Prime Healthcare

Acquires and reorganizes underperforming hospitals

Prime Healthcare operates a network of hospitals and outpatient centers across the United States, concentrating on turning around financially struggling facilities. It invests in infrastructure and technology, restructures operations, and negotiates payer terms (including pursuing higher out-of-network reimbursements) to improve financial performance, and it manages both for-profit hospitals and not-for-profit facilities through the Prime Healthcare Foundation. The company aims to raise clinical quality and patient safety while expanding access in hundreds of communities, though it has faced legal and regulatory scrutiny over billing practices and service-line decisions. Its goal is to stabilize and improve the financial and clinical performance of underperforming hospitals so they can continue serving their communities.

Company size: 5,001-10,000
Company stage: Debt Financing
Total funding: $2.2B
Headquarters: Ontario, CA
Founded: 2001

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