The RAC Manager serves as the primary contact and representative handling the data/documentation requests received based on the Government audits and manage the appeals process as part of the denial management. Is knowledgeable in the specific functions of the clerical positions and serves as a resource for co-workers. Is responsible for maintaining integrity of tracking Government review audits (RAC, MAC, CERT, OIG, Pre/Post Probes, HSAG and M-Cal), and others as they are created. Working with the Supervisor(s), a RAC manager functions as a subject matter expert (SME) for the appeals process and takes an active role in managing the process and coordinating with the RAC team, Corporate Utilization Review and Clinical appeals team. Provides supervision and direction for Medicare and Medicaid Appeals process along with analysis, resolution, monitoring & reporting of clinical denials. Facilitates peer to-peer following appeals submission for Fair Hearing for Medicaid audits. Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials. Reviews and determines appropriate strategy in response to reimbursement denials. Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration / CMO wherever applicable. In tandem with the Training Supervisor keeps abreast with the ongoing education/training to stay current with emerging industry trends on denials management. Performs ongoing audits; to monitor ADR requests and appeal/denial process and develops process improvement plans for identified deficiencies. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Performs other duties as assigned.

Required qualifications:

Preferred qualifications:

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.  Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.  A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $71,760.00 to $94,619.20 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.