Managed Care & Payer Relations  
Full Time
Day Shift 
Day

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina and the first hospital in the state to achieve Magnet with Distinction status for excellence in nursing care.

The 607-bed teaching hospital anchors a health care network that includes six community medical centers and employs more than 8,700 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina’s first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer’s care center and nearly 80 physician practices.  Its postgraduate medical education programs include family medicine and transitional year.

 

 

 

 

Job Summary

Responsible for coordinating, tracking and following up on all payer audit record requests, audit responses and appeals for the CMS Recovery (RAC) Program, CMS Medicaid Integrity Program, as well as all other Managed Care payer reviews for medical necessity, DRG and coding validation.

Minimum Qualifications

Minimum Education: High School Diploma or Equivalent
Minimum Years of Experience: 3 Years of experience hospital business office or medical setting and/or six months successful experience as a Business Office Associate.
Substitutable Education & Experience: None.
Required Certifications/Licensure: None.
Required Training: General knowledge of medical ethics and confidentiality;
Extensive knowledge of medical terminology, ICD-9/ICD-10, and CPT coding;
Personal computer proficiency with an emphasis on accuracy;
Ability to manipulate data in spreadsheets (i.e. Microsoft Excel) in order to report trends/patterns/statuses or abuses.

Essential Functions Receives, logs and tracks all RAC, MAC, CERT, other Government payer audit and Managed Care payer audit activity and correspondence. Works collaboratively with the Medical Records Department and ROI vendor to coordinate the sending and tracking of all medical record requests related to payer audits. Works collaboratively with the appropriate personnel and departments to facilitate timely appeal of payer audit denials. Follows up on outstanding medical record, audit requests and appeals to ensure they are responded to and resolved in a timely manner. Duties & Responsibilities Escalates status requests on account audits or appeals via monthly operational conference calls, as needed. Assists with preparation of audit activity reports on a monthly basis. Ensures proper documentation of activity or progress in EPIC and Payer Audit tracking software to  ensure that anyone viewing accounts will be aware of current status. Makes adjustments to account balances as appropriate and resolves secondary refunds needed in a timely manner. Performs all other duties as assigned.

We are committed to offering quality, cost-effective benefits choices for our employees and their families:

Day ONE medical, dental and life insurance benefits  Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one.  LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary  Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness

Equal Opportunity Employer
It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. LMC endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.