Regular Full Time
Responsibilities:
Focus of the Healthcare Documentation Auditor (DME FOCUUS) is the performance of timely and effective reviews to assess documentation and billing accuracy for post and prepayment claims on behalf of Government, and Commercial Payers.
Essential Functions:
Review medical records for services billed and validate required documents and information is contained within the records submitted for various service types as required by clients
Applying local coverage determination (LCD), national coverage determination (NCD), and commercial payer policy to services in review
Document and articulate review findings and reference the appropriate policies and rules in audit platform and as rationale language
Supporting findings during the appeals process if necessary
Working collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse
Partner with clients, CMD colleagues, and other contractors on improving policies, provider education, and system edits if necessary
Keep abreast of changes in technology and regulatory issues that may affect our business and clients
Suggest ideas that may improve audit work flows
Assist with QA functions as applicable
Participate in development of Review Guidelines and meetings as necessary
Assist with training team members as applicable
Cross train in other departments as applicable
Maintain required quality and productivity standards
Performs other duties as assigned.
*Note - 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 Performants policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Required Skills and Knowledge:
Knowledge of insurance programs, particularly the coverage and payment rules.
Demonstrated knowledge of medical terminology
Ability to maintain high quality work while meeting strict deadlines.
Excellent written and verbal communication skills.
Experience using the following applications is preferred: Word, Excel, and e-mail
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a platform to review and document findings
Must be able to manage multiple assignments effectively, organize and prioritize workload, problem solve, work independently and with team members
Courteous, professional, and respectful attitude
Flexibility to handle any non-standard situations that may arise
Additional Requirements:
Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.
Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.
Physical Requirements:
**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements). Basic office equipment required to perform remote work is provided by the company.
Basic office equipment required to perform remote work is provided by the company.
Job is performed in home-office setting (subject to Company approval and Teleworker Agreement), performs work at a desk or appropriate work surface, uses system and headset provided by the Company for 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 mouse.
Reads and comprehends information in electronic (computer) or paper form (written/printed).
Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.
Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.
Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment with account holders, may dial manually when need or use dialer system; headset is also provided.
Occasionally lift/carry/push/pull up to 10lbs.
Education and Experience:
High School Diploma or GED
Some college preferred
2+ years experience in adjudicating/examining claims for an Commercial Insurance Company, Tricare, MAC or organizations performing similar functions
5+ years experience of provider professional billing, coding and documentation practices in outpatient setting, DME, home health, infusion, or hospice to Commercial Insurance Companies, Medicare, Medicaid, Tricare, or organizations performing similar functions
Experience in quality assurance for internal compliance of billing practices
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Experience using Microsoft Excel and other Microsoft Office applications
Other Requirements:
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 clearances (as applicable).
Must submit to and pass pre-hire background check, as well as additional checks throughout employment.
Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.
Must submit to and pass drug screen pre-employment (and throughout employment).
Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.
Employment VISA Sponsorship is not available for this position
Job Profile is subject to change at any time.
EEO
Performant Financial Corporation is an Equal Opportunity Employer.
Performant Financial Corporation 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.
NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZED AGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDER
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