Performant Financial Corporation Looking for Medical Review Nurse Auditor at Livermore, CA  Full Time

Returning Applicant?

• Conduct medical chart reviews. Clinically validate the medical appropriateness and coding accuracy of services rendered in an inpatient setting.
• Accurately document clinical audit determinations within the audit tracking system, and maintain thorough and objective documentation of findings.
• Create narrative rationale to correspond audit determinations.
• As needed, support findings during the appeals process.
• Serve as a clinical resource; provide clinical expertise, and clinical guidance to the team.
• Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential Fraud Waste and Abuse (FWA).
• Monitors, tracks and reports on all work conducted.
• Consults with our clients, physicians, other clinical resources and contractors as necessary.
• Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives.
• As needed, assist with quality assurance functions, development of medical review and coding guidelines and training.
• Maintain a current knowledge of Medicare and Commercial regulations, policies and procedures
• Identify and recommends opportunities for cost savings and improving outcomes.
• Attend conference calls and meetings as requested.
• Maintain coding certification to ensure eligibility to perform audits on behalf of Performant
• Other duties, responsibilities, and qualifications may be required and/or assigned as necessary

*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 Performant’s policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination. Required Skills and Knowledge:

• Knowledgeable of the uses of ICD-9, ICD-10 PCS/HCPCS/CPT, MS-DRG codes
• Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding
• Familiarity with interpreting electronic medical records (EHR).
• Knowledge of insurance programs, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting deadlines and performance metrics.
• Excellent organizational, interpersonal and communication skills.
• Strong problem-solving skills.
• Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel).
• Must be able to independently use standard office computer technology (e.g. email, telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
• Acute sense of professionalism, attention to detail and confidentiality.
• Capability of working in a fast-pace environment, flexibility with assignments and the ability to adapt in a changing environment.
• Proficient in the use of CMS 1500/UB 04 forms.
• Flexibility to handle any non-standard situations that may arise Ability to multitask and work independently in a remote setting.
• Working knowledge of encoder.

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) until at which time staff may be notified and required to work from a Performant office location on an ad-hoc or periodic basis

Basic office equipment required to perform remote work is provided by the company.

* Job is performed in a standard busy office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or 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.

• Active unrestricted RN license in good standing.
• 2+ years clinical review and coding/auditing experience for an inpatient facility/SNF Facility
• 2+ years direct experience in medical chart review for all provider/claim types inpatient/outpatient
• 1-2 years experience working with healthcare claims demonstrating expertise in ICD-9/ICD-10 coding, HCPS/CPT-4 coding, and MS-DRG including medical billing experience for an Insurance Company or Hospital.
• Experience in conducting medical audits, investigations, reviewing and researching post service claims for aberrant billing patters, thorough review of the medical record documentation preferred.
• Experience with utilization management systems or clinical decision making tools such as MCG or InterQual.
• Proven ability to review, analyze, and research coding issues, a plus but not required.
• Reimbursement policy and/ or claims software analyst experience, a plus but not required
• Previous experience in either a provider or payer environment in claim processing, auditing, edit development, and/or coding and reimbursement policy a plus but not required

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.

*Applicants must have reliable, secure, high speed Internet access at their home office location.

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

Performant 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.