Recovery Audit Contractor (RAC)

The Recovery Audit Contractor (RAC) Auditor is responsible for determining the clinical necessity that supports the claim in accordance with the respective contract while also coordinating the disposition of the denied claim with the appropriate personnel.

• Must demonstrate an understanding of Medicare and other payer guidelines related to billing and charging of observation services, other separately chargeable services, and other lines of service.
• Must demonstrate knowledge of managed care contracting arrangements as well as notification and clinical review requirements.
• Must also be knowledgeable of regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. Possess the ability to perform a number of functions including those of internal auditing, coder education, liaison with external auditors for corporate audits.
• Registered Nurse license required.

Demonstrates the minimum knowledge, skills and abilities to recognize for the individualized needs of the patient to include physical, psychological, socio-cultural, spiritual and cognitive needs as well as functional abilities including the need for diversified use of such practices. Ability to understand and interpret medical records, hospital bills and Charge Master.

Must demonstrate an understanding of Medicare and other payer guidelines related to billing and charging of observation services, other separately chargeable services, and other lines of service. Must demonstrate knowledge of managed care contracting arrangements as well as notification and clinical review requirements. Must also be knowledgeable of regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity.

CPC or CCS required within 6 months of hire. Previous Healthcare Auditing experience preferred.

 

Education

• RN Bachelor Level Degree
• 2 yr RN Associate Degree
• RN Diploma

Certification/Licensure

• CPC or CCS required within 6 months of hire.
• Previous Healthcare Auditing experience preferred

Experience

• Demonstrates the minimum knowledge, skills and abilities to recognize for the individualized needs of the patient to include physical, psychological, socio-cultural, spiritual and cognitive needs as well as functional abilities including the need for diversified use of such practices
• Ability to understand and interpret medical records, hospital bills and Charge Master.
• Must demonstrate an understanding of Medicare and other payer guidelines related to billing and charging of observation services, other separately chargeable services, and other lines of service.
• 5 years Acute Care Coding experience required
• Registered Nurse required

Registered Nurse Coding Acute Care Medicare