Palmetto GBA

Business Analyst

• Evaluates the activities, performance and systems within a specific area for standards and workflow simplification.
• 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.
• Researches system problems and identifies potential solutions.
• Investigates and diagnoses system problems, formulates solutions, initiates change sheets, defines business requirements and tests corrections.
• Researches any questionable standard system or local component problematic situations to assure compliance and accuracy.
• Under general direction, defines business requirements, tests, and leads small to moderate projects.
• Assists management in performing business reviews by analyzing internal/external projects and changes.
• Ensures changes do not have a negative impact on productivity and procedures.
• Makes recommendations to improve productivity, cost effectiveness and timeliness.
• Communicates with management and departmental personnel to document workflow procedures.
• Assists in preparing verbal and written communication about business changes with management or other staff members.
• Prepares written reports and analyses pertaining to testing results and related data, including recommendations for customers on improving operational workflows.

Business Analyst II

Accounting Manager

• Under general supervision, performs a variety of routine to moderately complex clerical/accounting functions such as inventory balancing, reconciliations, generating refund request letters, processing disbursements and deposits, keying journal entries and logging items in accordance with standard procedures.
• Prepares various financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues, disputes, correspondence, or other data in support of the finance or accounting function.
• Ensures data is complete, accurate, and organized for processing.
• Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities for the position.
• Completes moderately difficult research using financial reporting systems, files, and other means to identify errors such as overpayments or misapplication of funds.
• Resolves routine questions and problems, referring complex issues to higher levels.
• Performs calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items.
• Provides other support duties related to the accounting/finance function that may include monitoring financial systems, keying journal entries, tracking funds, balancing accounts, maintaining inventory and receiving cash funds from customers, etc.
• May assists less experienced accounting clerks as needed. Determines, prepares, and distributes correspondence regarding monies due or erroneously received. Issues refunds as appropriate.

Technician, Accounting II – Medicare

Medical Reviewer

• 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
• Participate in quality control activities in support of the corporate and team-based objectives
• Perform 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, correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Document medical rationale to justify payment or denial of services and/or supplies

Medical Reviewer III

• Performs medical review 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.
• 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.
• Monitors process’s timeliness in accordance with contractor standards.
• 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 II

• 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, 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.
• Monitors process’s timeliness in accordance with contractor standards.
• 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.

Medical Reviewer II

• Evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
• Document decisions using indicated protocol sets, or clinical guidelines
• Provide support and review of medical claims and utilization practices
• Perform medical claim reviews and makes a reasonable charge payment determination
• Monitor process's timeliness in accordance with contractor standards
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Utilize allocated resources to back up review determination
• Conduct research necessary to make thorough/accurate basis for each determination made
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines

Medical Reviewer I

Accountant

• Reconciles assigned general ledger accounts of routine to moderate complexity
• Initiates and/or processes journal entries into various accounts
• Performs reviews of various systems activities for Financial and/or Operational reporting
• Prepares financial reports for financial analysis, forecasting, trending, budgeting, and/or results analysis
• Performs analyses of financial data to identify problem areas and/or report to management
• Prepares supporting reports and/or spreadsheets required to prepare financial reports
• Researches and/or completes account reconciliations to maintain accurate general ledger accounts
• Resolves out of balance situations and/or ensures outstanding items do not exceed standard timeframe
• Maintains documentation of work papers including costing, invoicing, allocation and/or other required auditable documents
• Assists with all audit preparation and/or review
• Assists internal and/or external auditors
• Assists supervisor with special projects

Accountant II

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.
• Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes.
• 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 and thus reducing lost time and involvement of corporate personnel.

Auditor II – Medicare Cost Reporting

• Conduct internal and/or external timely operational, financial, and/or compliance audits
• Identify, document, and evaluate business risks
• Develop written audit programs
• Conduct testing and analysis of existing controls to determine adequacy and effectiveness
• Prepare written work papers to document testing results
• Document issues, their causes, and effects on the corporation
• Serve as Lead Auditor on more complex assignments
• Draft recommendations to limit risks and improve processes
• Write audit reports for corporate executive management
• Collect and analyze data to detect deficiencies
• Conduct special audit studies for management
• Provide training to other auditors to maximize efficiency

Auditor III, Medicare

• Prepares various financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues, disputes, correspondence, or other data in support of the finance or accounting function.
• Ensures data is complete, accurate, and organized for processing.
• Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities for the position.
• Completes moderately difficult research using financial reporting systems, files, and other means to identify errors such as overpayments or misapplication of funds.
• Resolves routine questions and problems, referring complex issues to higher levels.
• Performs calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items.
• Provides other support duties related to the accounting/finance function that may include monitoring financial systems, keying journal entries, tracking funds, balancing accounts, maintaining inventory and receiving cash funds from customers, etc.
• May assists less experienced accounting clerks as needed.
• Determines, prepares, and distributes correspondence regarding monies due or erroneously received.
• Issues refunds as appropriate.

Accounting Technician II, Medicare

• Conducts internal and/or external 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
• Serves as Lead Auditor on complex audit assignments
• Writes audit reports for corporate management
• Collects and analyzes data to detect deficiencies
• Provides training to other auditors

Auditor III

Claims Specialist

• Reviews and adjudicates complex or specialty claims
• Determines whether to return, deny or pay claims following organizational policies and procedures
• Assists in training or mentoring new staff members
• Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines
• Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes
• Verifies that claims have been keyed correctly
• Ensures that claims are processing according to established quality and production standards
• Corrects processing errors by reprocessing, adjusting, and/or recouping claims
• Researches and resolves claims edits and deferrals
• Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas
• Responds to routine correspondence and completes spreadsheet if applicable

Claims Processor II

• 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
• Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes
• 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 and thus reducing lost time and involvement of corporate personnel

Business Analyst II

Technician, Accounting II – Medicare

Medical Reviewer III

RN Medical Reviewer II

RN Medical Reviewer II

Medical Reviewer II

Medical Reviewer I

Accountant II

Auditor II – Medicare Cost Reporting

Auditor III, Medicare

Accounting Technician II, Medicare

Auditor III

Claims Processor II

Medicare Cost Reporting Auditor II