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Job Description
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$146k
Per Year DOE (Depends on Experience) Recovery Audit Contractor (RAC) Manager
Prime Healthcare Management Inc.
Occupation:
Medical and Health Services Managers
Location:
Ontario, CA - 91764
Job Type:
Regular, Full Time (30 Hours or More), Permanent Employment
Posted:
06/22/2026
Positions available: 2
Source:
CalJOBS
Web Site:
CalJOBS
Onsite /
Remote:
Work onsite all of the time
Updated:
06/23/2026
Expires:
07/27/2026
Job #: 19858408
Job Requirements and Properties
Help for Job Requirements and Properties. Opens a new window. Work Onsite
Full Time Education
Master's Degree Experience
12 Month(s) Schedule
Full Time Job Type
Regular Duration
Permanent Employment Hours
40 Hours Per Week Public Transit
Available Benefits
Job Description
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JOB DUTIES
Serve as the primary contact for all Government Audit data and documentation requests, maintaining the integrity of tracking systems for RAC, MAC, CERT, OIG, HSAG, M-Cal, and other review audits. Oversee and manage Medicare and Medicaid denials and appeals to ensure improper payment denials are accurately validated, appeals are written appropriately, and submissions meet all deadlines. Function as a subject matter expert (SME) for the appeals process, partnering with Supervisors, the RAC team, Corporate Utilization Review, and Clinical Appeals to coordinate audit responses, monitor outcomes, and follow all RAC activities through closure. Lead the review of medical records and supporting documentation to prepare complete appeal packages and facilitate peer-to-peer discussions and Fair Hearings for Medicaid audits (30%). Supervise UR Supervisors, Medical Review Coordinators, UR Coordinators, and UR Technicians, ensuring efficient workflow, timely reporting, and accurate tracking of denials across Case Management, the Business Office, Coding, HIM, and Physician Advisors (35%). Maintain all denial and appeal databases, track RAC correspondence and activities, invoice record requests when applicable, and ensure compliance with HIPAA, state and federal regulations, and Medical Staff documentation requirements (5%). Use data analytics to identify denial trends, determine root causes, and develop strategies to reduce clinical and reimbursement denials, presenting findings to Administration, CMO, and relevant committees (5%). Support the Government Review Audits Committee by preparing agendas, dashboards, reports, and analysis, while communicating all new policies, memos, and payer requirements related to review audits (5%). Conduct ongoing audits of ADRs, denial and appeal processes, and documentation practices, addressing deficiencies through process improvement plans (10%). Develop internal training programs and partner with the Training Supervisor to stay current with industry trends, ensuring continuous education related to denial management and audit readiness (10%).
JOB REQUIREMENTS
Master's Degree in Healthcare Management, Healthcare Administration, Public Health, or any related field, plus 1 year of experience in denial management. Health education; Inpatient medical record review; Clinical knowledge of pathology/physiology of disease processes; Clinical criteria assessment for IP admissions; Proficiency in healthcare information tracking systems for RAC, MAC, CERT, OIG, HSAG, and M-Cal; Electronic Medical Records (EMR) and revenue cycle products, including EPIC, Meditech, Cerner, CPSI, OnBase, OneContent (formerly McKesson Patient Folder or Horizon Patient Folder), SSI, and Relay Health. Prime Healthcare Management Inc.
Is a Private Sector employer with 40 locations
