1+ months

Manager, Healthcare Audit Appeals

Sunrise, FL 33351
Regular Full Time

The Healthcare Audit Appeals Manager is a key member of the HCS organization and supports building a world class healthcare services business. This role directs the on time delivery of appeal determinations and other forms of appeal support services for our business ensuring organizational goals are met.  This position will provide direct oversight of multiple personnel and job functions to include (but not limited to): Appeal determinations, coordination of CMS discussion periods, facilitation of Appeal packets and the assessment and formulation of strategies for escalated appeals

Essential duties:
Collaborates with Medical Directors, Subject Matter Experts and Audit leadership to develop and document internal audit standards to align with individual audit concepts, claim types and client-specific policies.
Prepares reports and manages appeal activities for assigned clients, including the daily management of inventories to ensure adherence to all client and internal Service Level Agreements pertaining to Turn Around Times and Quality..
Applies in depth level of expertise in development of policies and procedures and workflows processes to conduct appeals, discussion periods, assess the level of engagement on escalated appeals, to ensure staff accurately identify processing, procedural, systemic and billing errors and practices leading to claims inaccuracies.
Manages team members performing appeal activities to identify trends, determine root cause of payment inaccuracies, monitor the quality fo auditor findings and to recommend process and systems improvements.
Proactively identifies opportunities for process improvement, efficiency, resolving problems, preparing and completing action plans.
Manages and trains team leaders and appeal  staff.  Supports staff recruitment, develops appeals auditors and builds effective teams.
Supports subcontractor communication, oversight and reporting.
Establishes accountability for performance monitoring (productivity/quality), communicates job expectations, trends, documentation, and ensures timelines are met.
Supports strategy by conducting needs assessments, capacity planning, cost/benefit analyses; preparing staffing models, establishing productivity and quality standards.
Maintains professional and technical knowledge by tracking emerging trends in audit management; attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
Develops effective relationships with leaders in the organization and has a strong understanding of the business.
Applies in-depth understanding of the inter-relationships of the business and support units throughout the organization.
Accomplishes organizational goals by accepting ownership of requests; exploring opportunities to add value.
Participates in business initiatives and pro-actively advises and assists the business on initiatives.
Builds HCS value and credibility with internal and external clients and represents the organization in meetings with the client, provider organizations, contractors, subcontractors and vendors.
Uses excellent communication skills in order to influence a wide range of internal and external audiences.
Provides timely response to escalated inquiries from the client and providers.
Supports other departments in problem resolution as necessary.
Completes required reports and ad hoc requests for information.
Inspires trust and credibility- delivers on commitments, audit subject matter expert.
Facilitates meetings as necessary.
Performs other duties as assigned


*Note - 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 Performants policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Required Skills and Knowledge:
Possess a broad and comprehensive understanding of audit standards, policies and regulations, applies a broad and comprehensive knowledge in areas including, medical chart reviews.
Strong project management and interpersonal skills, makes sound decisions, exhibiting initiative and intuitive thinking. Consulted often by others for advice and opinions and recognized as a leadership role model.
Problem solving, strong analytical skills, people skills, teamwork, people management, and managing processes.
Strong interpersonal skills for interfacing with all levels of internal and external audit teams and management.
Ability to prioritize and multi task.
Must be a strong effective communicator, both orally and in writing, with an energetic, charismatic and approachable style.
Proven experience in managing high performing dynamic teams.
Ability to work in a diverse and fast paced environment.
Strong working knowledge of MS Office

Ability to obtain and maintain client required clearances, if applicable, 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:
Job is performed in busy standard 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.


Education and Experience:
BA/ BS or 10+ years of business experience in healthcare with increasing responsibility directly relevant to the job.
Preference for prior experience overseeing audit or appeal-related operations, including responsibility for inventory assignments, SLA management and communication of audit results.


Other Requirements

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

Visa sponsorship is not available.

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. 



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Posted: 2021-03-19 Expires: 2021-06-13
Analytics, audit, and recovery services for healthcare, government and student loans.

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Manager, Healthcare Audit Appeals

Performant Financial
Sunrise, FL 33351

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