RAC Manager
$71,760–$94,619 year
On-siteOntario, Canada or Us, Île-de-France, France
Job Summary
Manage Government audit appeals and denial management processes, including RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG, and M-Cal audits. Serve as a subject matter expert coordinating with the RAC team, Corporate Utilization Review, and Clinical appeals teams to analyze, resolve, and monitor clinical denials. Facilitate peer-to-peer reviews for Fair Hearing Medicaid audits and act as a liaison between Case management, Business office, and Coding teams to ensure timely reporting. Conduct ongoing audits to monitor ADR requests, develop process improvement plans, and coordinate data analytics to identify denial trends. Stay current with emerging industry trends through ongoing education and training.
Required Qualifications
- Master's in healthcare
- one year experience in denial management
Desired Qualifications
- ECFMG Certification
- Bachelor's or higher from a US-based accredited institution in a Health and Human Services field
- Extensive knowledge of nursing care
- clinical measurement tools
- clinical outcomes
- ability to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare disciplines
- program and database development
- 1+ year of clinical experience in acute care setting
- 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
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