Location Address: 4200 Sun 'n Lake Boulevard Sebring, FL 33872
Top Reasons to Work at AdventHealth Sebring
Faith Based & Mission driven Facility
Largest Employer in the County
Surrounded by beautiful Lakes, Golf Courses and Florida’s oldest State Park
Close knit community with a home town family feel
2 hours to just about any beach on either Coast
Work Hours/Shift: Full Time Days
Responsible for organizing and managing the audit process and the tracking of outcomes involving Recovery Audit Contractor (RAC) requests. Responsible for Medicare patient related billing audits and outcomes such as patient disputed charges and denials by Medicare or any payers as deemed necessary. Responsible for monitoring RAC Manager Software program. Responsible for following up with the designated RAC on pending appeals. Prepares and analyzes data related to RAC performance
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
Responsible for receiving all communication from Recovery Audit Contractors and disseminating to designated hospital leadership.
Monitor RAC website to review outstanding claims currently under audit and follow-up with designated RAC appeals staff as required.
Communicates to HIM requests for medical records and reviews medical record prior to submission to ensure all required documentation is present and is appropriately formatted for submission and attaching same to account in RAC Manager. Enter request in RAC Database for MR submission.
Utilizes RAC Manager tracking and reporting database to download Medical Record (MR) and enter all required entries into database to request CD/DVD submission by vendor. Records all MR requests into RAC Manager database as designated by supervisor.
Responsible for monitoring database to ensure MR requests are submitted in a timely fashion, enters redetermination and demand results for all appeal levels.
Assure request related to DRG changes are communicated to the HIM designated DRG auditor and coding staff , receive outcomes of the DRG review as done by the DRG auditor and record (attach) those outcomes in RAC Manager program, in concurrence with the RAC or appeals process.
Reviews all Medical Necessity denials and confers with Coding staff, Care Coordination and Revenue team to determine if appeal is appropriate and should be pursued.
Drafts appeal letters or submits demand letters to third party organization contracted too appeal on behalf of the provider.
Coordinated and reports RAC results and appeal status to Administration, Utilization Review Committee and/or Finance Committee as designated by supervisor.
Acts as a liaison for HIM, Corporate Clinical Compliance and Care Coordination in the RAC Process.
Assures that all outcomes are logged and communicated to Patient Financial Services for follow-up.
Assures follow-up of all appeals to ensure timely filing of appropriate level of appeals.
Monitors remittance results and reports to supervisor for account follow-up as appropriate.
Participates in meetings, teleconferences and Webinars as required.
Attend RAC webinars or onsite meetings to stay current with RAC targeted DRGs and issues.
Monthly statistical report compilation. Gather and report information to Administration upon request.
Performs medical record reviews for Medical Necessity or discharge disposition for various governing bodies as required, such as the Medicare PRO/Medicaid PRO, or any other third party payer.
Will provide oversight of the RAC process. Will assist with training others within the hospital (HIM, Case Management, PFS) in the RAC process as directed.
KNOWLEDGE AND SKILLS REQUIRED:
Demonstrates the ability to apply to high degree abstract reasoning and technical skills.
Must be proficient with computer applications, including but not limited to : Windows, Outlook, Excel, Microsoft Word
EDUCATION AND EXPERIENCE REQUIRED:
Advanced degree, preferably in management or fiscal area.
EDUCATION AND EXPERIENCE PREFERRED:
Two (2) years previous experience as a RAC Coordinator in highly preferred
Denials/Appeal Data Management or Financial Services Experience will be considered.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.