Palmetto GBA

Analyst

• Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests.
• Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines.
• Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Analyst, Appeals

General

• Identifying, developing, and implementing process improvements and automation solutions that enhance operational efficiency within the Audit Reimbursement Department.
• Evaluates existing policies, procedures, and workflows to recommend improvements.
• Collaborates with department stakeholders to streamline operations, reduce manual effort, improve accuracy, and support continuous improvement initiatives.
• Compiles data for analysis and prepares reports and presentations for management using applicable programming languages and/or software products.
• Reviews system enhancements/upgrades to determine applicability of customer file modification requirements.
• Facilitates timely and accurate updates to reference files based on customer requests.
• Coordinates testing and debugging of new or modified software.
• Creates test matrices and supporting documentation.
• Develops and executes formal test plans to ensure delivery of quality software applications.
• Monitors software implementations for exceptions and to verify that changes to the systems' operational process had the desired effect.
• Identifies and documents systems problems and assists in their resolution.

Automation Specialist

Accountant

• Responsible for analyzing and researching complex healthcare and financial data to identify, investigate, and resolve variances within Medicare Cost Reports
• Ensures accurate determination of settlements and reimbursement rates while maintaining compliance with regulatory requirements and meeting all reporting deadlines with accuracy and timeliness
• Reconciles assigned accounts
• Initiates and/or processes general ledger and/or journal entries into various accounts
• Prepares spreadsheets and/or ensures that entries are entered into the accounting system
• Assists coworkers in preparation and/or review of daily activity, monthly, quarterly and/or annual filings as required
• Prepares reports for financial analysis, forecasting, budgeting, trending, and/or results analysis

Accountant I, Medicare

Medical Reviewer

• Perform medical claim reviews for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
• Monitors process’s timeliness in accordance with contractor standards
• Document medical rationale to justify payment or denial of services and/or supplies
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc.
• Participate in quality control activities in support of the corporate and team-based objectives
• Provide guidance, direction, and input as needed to LPN team members
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assists with special projects and specialty duties/responsibilities as assigned by management

Reviewer II, Medical

Auditor

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls
• Identifies, documents, and evaluates business risks
• Documents issues, the causes of those issues, and their effects on the process/function and the corporation
• Drafts recommendations to limit risks and improve processes, functions and activities
• Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations
• Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies
• Conducts testing of corrective actions as identified
• Develops detailed reports on each audit conducted
• Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud
• Prepares reports of findings and recommendations for management
• Assists other auditors in completing their assignments as a means of maximizing audit efficiency

Medicare Cost Reporting Auditor II

• Conducts internal and/or external timely operational, financial, and/or compliance audits
• Identifies, documents, and evaluates business risks
• Develops written audit programs
• Conducts testing and analysis of existing controls
• Prepares written work papers to document testing results
• Documents issues, the causes of those issues, and their effects on the corporation
• Serves as Lead Auditor on more complex audit assignments
• Drafts recommendations to limit risks and improve processes
• Writes audit reports for corporate executive management
• Collects and analyzes data to detect deficient controls, fraud, or non-compliance
• Develops detailed reports on each audit conducted
• Examines and evaluates financial and information systems, recommending controls
• Conducts special audit studies for management
• Provides training to and assists other auditors

Medicare Cost Reporting Auditor III

• Conduct internal and/or external operational, financial, and/or compliance audits
• Evaluate internal controls and identify business risks
• Develop written audit programs and test existing controls
• Document testing results and conclusions
• Draft recommendations to limit risks and improve processes
• Write audit reports for corporate executive management
• Analyze data to detect deficient controls or fraud
• Conduct special audit studies for management and train other auditors

Auditor III

• Maintains all quality management system documentation at the company level
• Assists and trains functional document control administrators and management in documenting procedures in accordance with certification standards
• Provides support for the Quality Management System (QMS)
• Provide weekly metrics on new, in progress, and completed medical records requests
• Maintain a consistent workflow by processing all requests within 24-48 hours of receipt for assigned medical records tickets
• Manage, organize, copy, scan, and analyze medical records to ensure accuracy, integrity, and timely fulfillment of medical record requests
• Travel to providers offices to complete medical record requests via Electronic Medical Records Systems
• Manage electronic and physical records, ensure compliance with federal regulations and agency directives, and support the full records lifecycle from creation to disposition
• Stay up-to-date with medical records and health information release regulations (e.g., HIPAA)
• Provides document control administrator and management training and support for QMS
• Updates ISO 9000 and quality management documentation at the company level
• Maintains files, records, and documentation in accordance with certification standards
• Works with vendor, document control administrators, and management to maintain and enhance the QMS documentation system as well as to maintain, develop and test any enhancements
• Compiles performance metric reports, management review reports, and score cards
• Provides documentation control for management review meetings
• Prepares and distributes minutes and task list
• Plans internal/external audits
• Performs documentation audits for auditors
• Documents audit findings in a final report presentation

Records Coordinator

Medical Director

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on issues concerning medical policies
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

Physical Medicine and Rehabilitation Medical Director

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines
• Documents decisions using indicated protocol sets or clinical guidelines
• Provides support and review of medical claims and utilization practices
• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
• Documents medical rationale to justify payment or denial of services and/or supplies
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participates in quality control activities in support of the corporate and team-based objectives
• Provides guidance, direction, and input as needed to LPN team members
• Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback
• Assists with special projects and specialty duties/responsibilities as assigned by Management

RN Medical Reviewer III

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff.
• Ensures appropriate levels of healthcare services are provided.
• Functions as a team leader/senior-level Medical Reviewer.
• Provides leadership/guidance/direction/training to staff.
• Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow.
• Acts as a resource for staff/external entities troubleshooting as well as resolving issues.
• Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews.
• Follows a process to ensure quality plan is adhered to and communicated to all parties.
• Gives/receives feedback regarding medical review decision making and technical claims processing issues.
• Ensures that quality work instructions/forms/documents are developed/revised as needed.
• Provides quality service and communicates effectively with external/internal customers in response to inquiries.
• Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participates in compliance initiatives and other directed activities.
• Participates/oversees special projects as requested by management.