Manager, Healthcare Audit Appeals

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:

The Healthcare Audit Appeals Manager is a key member of the HCS organization and supports building a world class healthcare services business. This role directs the on-time delivery of appeal determinations and other forms of appeal support services for our business ensuring organizational goals are met. This position will provide direct oversight of multiple personnel and job functions to include (but not limited to): Appeal determinations, coordination of CMS discussion periods, facilitation of appeal packets and the assessment and formulation of strategies for escalated appeals. This position also provides oversight of all commercial appeals ensuring compliance with various client protocols, processes and timelines.

Key Responsibilities

• Collaborates with Medical Directors, Subject Matter Experts and Audit leadership to develop and document internal audit standards to align with individual audit concepts, claim types and client-specific policies.
• Prepares reports and manages appeal activities for assigned clients, including the daily management of inventories to ensure adherence to all client and internal Service Level Agreements pertaining to Turn Around Times and Quality.
• Applies in depth level of expertise in development of policies and procedures and workflows processes to conduct appeals, discussion periods, assess the level of engagement on escalated appeals, to ensure staff accurately identify processing, procedural, systemic and billing errors and practices leading to claims inaccuracies.
• Manages team members performing appeal activities to identify trends, determine root cause of payment inaccuracies, monitor the quality of auditor findings and to recommend process and systems improvements.
• Proactively identifies opportunities for process improvement, efficiency, resolving problems, preparing and completing action plans.
• Manages and trains appeal staff. Supports staff recruitment, develops appeals auditors and builds effective teams.
• Supports subcontractor communication, oversight and reporting.
• Establishes accountability for performance monitoring (productivity/quality), communicates job expectations, trends, documentation, and ensures timelines are met.
• Supports strategy by conducting needs assessments, capacity planning, cost/benefit analyses, preparing staffing models, establishing productivity and quality standards.
• Maintains professional and technical knowledge by tracking emerging trends in audit management; attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
• Develops effective relationships with leaders in the organization and has a strong understanding of the business.
• Applies in-depth understanding of the inter-relationships of the business and support units throughout the organization.
• Accomplishes organizational goals by accepting ownership of requests; exploring opportunities to add value.
• Participates in business initiatives and pro-actively advises and assists the business on initiatives.
• Builds HCS value and credibility with internal and external clients and represents the organization in meetings with the client, provider organizations, contractors, subcontractors and vendors.
• Uses excellent communication skills to influence a wide range of internal and external audiences.
• Provides timely response to escalated inquiries from the client and providers.
• Supports other departments in problem resolution as necessary.
• Completes required reports and ad hoc requests for information.
• Inspires trust and credibility- delivers on commitments, audit subject matter expert.
• Facilitates meetings as necessary.
• Performs other duties as assigned.

Knowledge, Skills and Abilities Needed

• Possess a broad and comprehensive understanding of audit standards, policies and regulations, applies a broad and comprehensive knowledge in areas, including medical chart reviews.
• Strong project management and interpersonal skills, makes sound decisions, exhibiting initiative and intuitive thinking. Consulted often by others for advice and opinions and recognized as a leadership role model.
• Problem solving, strong analytical skills, people skills, teamwork, people management, and managing processes.
• Strong interpersonal skills for interfacing with all levels of internal and external audit teams and management.
• Ability to prioritize and multitask.
• Must be a strong effective communicator, both orally and in writing, with an energetic, charismatic and approachable style.
• Proven experience in managing high performing dynamic teams.
• Ability to work in a diverse and fast paced environment.
• Strong working knowledge of MS Office

Required and Preferred Qualifications

• Active Registered Nurse license required. Bachelor's degree preferred.
• At least 10 years of experience with increasing responsibility directly relevant to the job; 5 or more years of Medical Coding experience is required. The ideal candidate in this role will be a Nurse Coder, with extensive Clinical and Coding knowledge.
• Leadership experience is required, minimally at the Supervisor level; manager level or above is preferred.
• Strong preference for prior experience overseeing audit or appeal-related operations, including responsibility for inventory assignments, SLA management and communication of audit results.

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