Healthcare Quality Assurance Specialist (Licensed Practical Nurse)

ABOUT PERFORMANT:

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work, we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matters most – quality of care and healthier lives for all.

If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

ABOUT THE OPPORTUNITY:

Hiring Range: $50,000-$65,000

The Medical Review Nurse (LPN) primarily performs medical claims audit reviews. As an MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work in a fast-paced, dynamic environment and be part of a multi-location team who are dedicated to this important work.

In this role, you will be responsible for:

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings.
• Applying appropriate medical review guidelines, policies, and rules
• Documenting all findings referencing the appropriate policies and rules
• Generating letters articulating audit findings
• Supporting your findings during the appeals process if requested
• Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.
• Suggesting ideas that may improve audit workflows.
• Other duties may be assigned as required to meet business needs.

Knowledge, Skills, and Abilities needed:

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with ICD-9, ICD-10, CPT-4, or HCPCS coding.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Ability to maintain high-quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Not currently sanctioned or excluded from the Medicare program by the OIG.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology (e.g., email telephone, copier, etc.) and have experience using a case management system/tool to review and document findings.
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload.
• Work independently and with team members effectively.

Education and Experience Requirements:

• Minimum of three (3) years diversified nursing experience providing direct care in an inpatient or outpatient setting.
• Active and unrestricted LPN or LVN license in good standing is required.
• One (1) or more years’ experience performing medical records review.
• One (1) or more years’ experience in healthcare claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an insurance company or hospital is preferred.

WHAT WE OFFER:

Performant offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, disability coverage options, life insurance coverage, 401(k) savings plans, paid family/parental leave, 11 paid holidays per year, as well as sick time and vacation time off annually. For more information about our benefits package, please refer to our benefits page on our website or ask your Talent Acquisition contact during an interview.

Physical Requirements & Additional Notices:

If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee’s responsibility to maintain this Internet access at their home office location.

The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.

• Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.
• Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).
• Regularly sit/stand 8 or more hours per day.
• Occasionally lift/carry/push/pull up to 10lbs.

Performant is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug-Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:

• Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.
• Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.
• Must complete the Performant Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.

Other requirements may apply.

All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Performant’s policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Performant is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Performant will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Performant’s Human Resources team to discuss further.

Our diversity makes Performant unique and strengthens us as an organization to help us better serve our clients. Performant is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.