Specializing in you...serving San Diego´s inland North County communities for more than 50 years, Palomar Pomerado Health is a family of outstanding healthcare facilities that cover an area of more than 800-square miles.
Managed Care RAC AnalystPalomar Pomerado HealthFull TimeSpecializing in you...serving San Diego´s inland North County communities for more than 50 years, Palomar Pomerado Health is a family of outstanding healthcare facilities that cover an area of more than 800-square miles. We are the largest hospital district in Southern California and the first California designated health system to receive ANCC Magnet® Recognition. From our state-of-the-art Cardiac Care and Rehabilitation Facilities and busy Trauma Center to Home Healthcare, we deliver a full spectrum of health services to meet the needs of every member in our community. We have an excellent opportunity for a Managed Care RAC Analyst. A Recovery Audit Contractor (RAC) Analyst requires a diverse set of organizational skills, medical chart review and analysis, knowledge of claims appeal process and ability to apply (Interqual, Milliman) practice management guidelines to determine medical necessity. Responsibilities include:• Research complex issues pertaining to Medicare & Medi-Cal reimbursement/payment polices. • Ability to synthesize the information, concisely communicate either verbally or in writing findings and recommendations. • Responsible to present and/or defend audit findings to appropriate internal and external stakeholders (i.e. hospitals, physicians, attorneys, judges, etc). • Creatively and effectively solve problems, develop and implement policy and procedures, perform analysis and prepare reports. • Provides backup support for PFS Denials RN as needed. • Trains/mentors Denials RN on all facets of RAC program for coverage as needed. • Performs other duties as assigned. • Follows PPH rules, policies, procedures, applicable laws, and standards. • Carries out the mission, vision, values, and quality commitment of PPH.We promote a philosophy that encourages growth and satisfaction. We provide a work environment that is open and empowering, where you can experience a wide range of clinical, educational, and management opportunities. We also support a healthy balance between your personal and professional lives. We are located in an area that is enriched with a sense of belonging, where everyone pulls together in a common philosophy of life. It´s an area that affords all who live here the luxury to pursue any interest or lifestyle they choose.RequirementsMinimum Education: As required by certification and/or licensurePreferred Education: Bachelor´s Degree in nursing, healthcare, business administration, accounting or related fieldMinimum Experience:- 2 years case management, utilization review, or denials management. Independent thinker, logical, strategic, with an attention to detail.- Effective communication style (written and verbal) with proven ability to positively influence behavior and outcomes.Preferred Experience: Clinical Documentation Integrity (CDI) and legal experience with demonstrated success researching local, state and federal laws and regulationsRequired License: Current CA RN License and Valid Driver´s LicenseWe invite you to join us in our Mission to Heal, Comfort, and Promote Health in the Communities We Serve!