RAC & Payer Audit Coordinator

Managed Care & Payer Relations

Full Time

AM Shift

40.0

Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer.

Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.

Job Summary

Responsible for coordinating, tracking and following up on all payer audit record requests, audit responses and appeals for the CMS Recovery (RAC) Program, CMS Medicaid Integrity Program, as well as all other Managed Care payer reviews for medical necessity, DRG and coding validation.

Minimum Qualifications

Minimum Education: High School Diploma or Equivalent

Minimum Years of Experience: 3 Years of experience hospital business office or medical setting and/or six months successful experience as a Business Office Associate.

Substitutable Education & Experience: None.

Required Certifications/Licensure: None.

Required Training: General knowledge of medical ethics and confidentiality;

Extensive knowledge of medical terminology, ICD-9/ICD-10, and CPT coding;

Personal computer proficiency with an emphasis on accuracy;

Ability to manipulate data in spreadsheets (i.e. Microsoft Excel) in order to report trends/patterns/statuses or abuses.

Essential Functions

• Receives, logs and tracks all RAC, MAC, CERT, other Government payer audit and Managed Care payer audit activity and correspondence.
• Works collaboratively with the Medical Records Department and ROI vendor to coordinate the sending and tracking of all medical record requests related to payer audits.
• Works collaboratively with the appropriate personnel and departments to facilitate timely appeal of payer audit denials.
• Follows up on outstanding medical record, audit requests and appeals to ensure they are responded to and resolved in a timely manner.
  
  

Duties & Responsibilities

• Escalates status requests on account audits or appeals via monthly operational conference calls, as needed.
• Assists with preparation of audit activity reports on a monthly basis.
• Ensures proper documentation of activity or progress in EPIC and Payer Audit tracking software to ensure that anyone viewing accounts will be aware of current status.
• Makes adjustments to account balances as appropriate and resolves secondary refunds needed in a timely manner.
• Performs all other duties as assigned.
  
  

We are committed to offering quality, cost-effective benefits choices for our employees and their families:

• Day ONE medical, dental and life insurance benefits
• Health care and dependent care flexible spending accounts (FSAs)
• Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
• Employer paid life insurance – equal to 1x salary
• Employee may elect supplemental life insurance with low cost premiums up to 3x salary
• Adoption assistance
• LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
• Tuition reimbursement
• Student loan forgiveness
  
  

Equal Opportunity Employer

It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.

Nearest Major Market: Columbia

Nearest Secondary Market: South Carolina