The Health Care Services Segment Specialist Government Programs applies specific subject matter expertise in Medicare Payment Integrity policy and claims to support of audit business activity performing the following essential duties:

• Development of rule specifications and medical review instruments in accordance with regulatory policies and national coding guidelines
• Subject matter expert (SME) for the Education team with development or updates to training material(s) for new and/or existing issues.
• Subject matter expert (SME) supporting Performants responses to provider or client representative inquiries as it pertains to audited CMS claims, as necessary.
• Participate in calls with providers or client representatives related to reviews or appeals of audited CMS claims, as necessary.
• Support strategic CMS market development by attending industry conferences or other events.
• Provide leadership of CMS audit strategy as per each unique contract.
• Manage QA of approved issues applying coding, citation, or regulatory changes delivering results to client on time.
• Manage QA of audit performance per audit issue.
• Create and maintain audit issues through research, data analysis, preparation of rule documents and/or code lists.
• Evaluate existing audit guidelines with recommendations to improve finding rate, reduce dispute or appeal rates and decrease overturn rate.
• Maintain review guidelines and ADR requirements, as necessary.
• Subject matter expert (SME) supporting analytic, audit and clinical teams as necessary.
• Ensure issues are well formulated for CMS or OIG offerings (Data Mining vs Complex Audit).
• Support statistical analysis to drive scoring and selections of audit issues.
• Other duties as assigned.

• Bachelor's degree in related field or equivalent work experience.
• RN licensure with significant coding experience or coding certification preferred.
• Minimum 8+ years Healthcare Payment Integrity experience preferred.
• Progressive health care data analysis experience
• CMS contractor (e.g., MAC, UPIC) experience preferred.

• Demonstrated knowledge of CMS and regulatory policy.
• Expertise in ICD-9-CM, ICD-10-CM/PCS, CPT-4, and HCPCS coding.
• Broad knowledge of healthcare nationally accepted coding conventions.
• Ability to work independently and ensure projects are completed with quality results.
• Ability to manage multiple tasks and track multiple issues during all phases of development.
• Strong interpersonal skills: ability to communicate effectively within all levels of the organization.
• Excellent written and verbal communication skills.
• Excellent critical thinking and listening skills.
• Strong analytical and problem-solving skills, including the ability to analyze health services utilization data (e.g., claims data).
• Flexibility to handle non-standard situations and adapt to changing business needs in a fast-paced dynamic environment.
• Time management skills for managing multiple tasks simultaneously, while completing work within allocated time frames in a remote environment
• Proficient in Microsoft Office, SharePoint, Confluence (advanced skills highly desirable).

Additional Requirements:

Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.

Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety& ergonomics, confidentiality, and dedicated work focus without distractions during work hours.

Physical Requirements:

**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements) until at which time staff may be notified and required to work from a Performant office location on an ad-hoc or periodic basis.

Basic office equipment required to perform remote work is provided by the company.

Job is performed in a standard busy office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or headset provided by the Company for 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 mouse.

Reads and comprehends information in electronic(computer) or paper form (written/printed).

Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.

Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.

Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment with account holders, may dial manually when need or use dialer system; headset is also provided.

Occasionally lift/carry/push/pull up to 10lbs.

Other Requirements:

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 clearances (as applicable).

Must submit to and pass pre-hire background check, as well as additional checks throughout employment.

Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.

Must submit to and pass drug screen pre-employment (and throughout employment).

Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.

Employment VISA Sponsorship is not available for this position.

Job Profile is subject to change at any time. 

Performant Financial Corporation is an Equal Opportunity Employer.

Performant Financial Corporation 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.

NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZEDAGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDERS.