Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

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.

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf