RAC Manager

Prime Healthcare; Racimo (CA); Presencial; USD 72.000 - 95.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

401K retirement plan

Medical insurance

Dental coverage

Vision coverage

Tuition reimbursement

Paid time off

Descripción de la vacante

Prime Healthcare is seeking a RAC Manager to serve as the primary contact for data and documentation requests arising from government audits and the appeals process. The role coordinates with RAC teams, Corporate Utilization Review, and clinical appeals to manage denials and ensure timely reporting.

Candidates should bring experience in denial management; strong communication, analytical, and interpersonal skills, and a solid understanding of Medicare/Medicaid guidelines and hospital operations.

Formación

• Master’s in healthcare with one year experience in denial management.
• ECFMG Certification and/or Bachelor's or higher from a US-based accredited Health and Human Services field preferred.
• 1+ year of clinical experience in acute care setting preferred.
• Excellent written and verbal communication skills.
• Excellent interpersonal skills to build effective partnering relationships.

Responsabilidades

• Handle data/documentation requests for government audits and manage the appeals process.
• Maintain integrity of tracking Government review audits (RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG and M-Cal).
• Coordinate with RAC team, Corporate Utilization Review and Clinical appeals team.
• Provide supervision and direction for Medicare/ Medicaid Appeals process and analysis of denials.
• Monitor denial trends and report findings to administration.

Conocimientos

Communication skills

Critical thinking

Interpersonal skills

Educación

Master’s degree in healthcare

ECFMG Certification or US health-related degree

Descripción del empleo

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.

• paid time off
• a 401K retirement plan
• medical
• dental
• vision coverage
• tuition reimbursement
• 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