Medical Review Clinical QA Auditor (RN) - Home Health & Hospice

ABOUT PERFORMANT:

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all.

If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

ABOUT THE OPPORTUNITY:

Hiring Range:$78,500 - $85,000

The Medical Review Clinical Quality Auditor (RN) is responsible for conducting Quality Assurance (“QA”) reviews of medical review audit work completed by the medical review audit team members to ensure the accuracy of claim findings and applicable documentation for our clients both Government and Commercial payors.

Key Responsibilities:

• Conducts quality assurance reviews on medical review audit work completed by the audit team members, maintaining productivity and quality standards as defined by department policy.

• Objectively and accurately documents quality review results in accordance with department quality policies and procedures, scoring and reporting all QA results in an approved QA tracking system and routes record appropriately within audit platform based upon how QA review resulted in concurrence with audit finding or identified corrections required. 

• Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings. 

• Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings

• Contributes to the continuous improvement feedback process and suggests or makes any edits, documentation, next steps, and reporting as may be necessary in accordance with department process and audit leadership direction.

• May support findings during the appeals process, if needed.

• May perform primary audit activity as assigned by management.

• Monitors, tracks, and reports on all work conducted in accordance with QA process and management direction. 

• May prepare QA reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept based/trended, or other characteristic that will provide valuable business insights.

• Consults with internal resources as necessary.

• Become subject matter expert for assigned business segment(s).

• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.

• Participates in and contributes to applicable department meetings.

• Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position.

• Proactively contributes to continuous improvement of activities and sets positive example 

• Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.

• May support training material/tools and best practices development.

• May identify/make recommendations to management for supplemental team/concept type training.

• May support training activities for new audit staff or provide supplemental training for existing staff as needed.

• Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results. 

• Receives feedback and adjusts work priority as necessary.

• Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law.

• Performs job duties with high level of professionalism and maintains confidentiality

• Perform other incidental and related duties as required and assigned to meet business needs.