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RCM Quality Control Representative

Company: DJO
Location: Trenton
Posted on: August 5, 2022

Job Description:

Job Description

The Quality Control (QC) Representative provides daily review for Medicare and Medicare Advantage orders prior to billing to ensure quality and compliance with CMS guidelines. This position is also responsible for partnering with Revenue Cycle Management (RCM) Leadership and the Compliance Team to ensure compliance with Company policies and procedures, industry standards, payor requirements, and applicable federal and state laws related to DMEPOS procurement and billing. This is a great opportunity to join an evolving Revenue Cycle Management (RCM) Team dedicated to supporting our CMF Bone Growth Stimulator business!

Job Responsibilities

Audit Responsibilities

  • Compiles, reviews, and evaluates required documentation specific to government and commercial payors.
  • Ensures documents needed for billing are accurate, legal, and in compliance with both Company and regulatory standards.
  • Reviews completed documents against system data to ensure accuracy.
  • Interacts with external contacts (e.g., Distributor Partners, physician clinics, etc.) to coordinate activities related to internal and external audit responses.
    Quality Control Responsibilities
    • Reviews Medicare and Medicare Advantage accounts daily prior to invoicing.
    • Coordinates daily workflow of quality control invoicing, analyzing, and reporting outcomes and identifying gaps, and recommends needed process improvements.
    • Answers questions from Sales and/or RCM teams related to government and commercial payor requirements.
    • Provides accurate and timely response to Sales Representatives and other internal customers as it relates to Returned Quality Control (RQC) orders.
    • Monitors trends and/or changes associated with applicable coding, documentation, and other requirements and works with Management to remediate, when possible.
    • Corrects errors in documents and/or system data.
    • Resolves exception processing issues.
    • Researches various documentation, billing, and other issues that arise and recommends corrective actions needed to resolve identified issues and process orders accurately.
    • Compiles data for management review to assist in making strategic and tactical recommendations to front and backend processes.
    • Collaborates with team members to create, edit, update, distribute, and modify various resources which include, but are not limited to, policies, procedures, user tools, departmental educational offerings, and payor-related information.
    • Provides feedback and training guidance to the RCM Team and other internal departments.
    • Identifies training needs and recommends learning tools with the goal of continuously improving RCM performance and to better enable the team to operate in a compliant manner.
      • Demonstrates commitment to the DJO Compliance & Ethics Program, the DJO Code of Conduct, the DJO Sales and Marketing Code of Conduct, the AdvaMed Code of Ethics, and all supporting and applicable regulations, policies, and procedures.
      • Adheres to all internal Corporate Compliance guidelines, OIG, government healthcare regulations, regulatory policies and procedures, and privacy and security standards in accordance with government agencies, including HIPAA requirements.
      • Treats Protected Health Information (PHI) with the strictest confidentiality in accordance with HIPAA standards.
      • Acquires a basic understanding of the field to include regulatory compliance issues and adheres to these guidelines.
      • Other duties as assigned.
        • Minimum of 5 years of experience in RCM operations in a health care industry, auditing, clinical operations, privacy, or compliance required.
        • Associate Degree in Business or Health Care Administration, or related field, preferred.
        • Experience must include complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system.
        • Knowledge of standard coding (e.g., HCPCS) and applicable reference materials used in a revenue cycle management operation required.
        • Knowledge of health care benefit structures and insurance procedures required.
        • Knowledge of CMS requirements regarding claims processing, specifically DMEPOS claim processing rules and regulations, required.
        • Proficiency in processing/auditing Medicare, Medicaid, and commercial plans required.
          • This position does not require travel.
            • Typical office environment.
            • Physical Demands: May occasionally lift up to 10 pounds. Routinely uses standard office equipment such as computers, keyboard, phone, print. Required to talk and hear. Must be able to sit and stand for extended periods of time and use hands and fingers to handle or feel, and to manipulate keys on a keyboard and operate portable input devices (e.g., smart phone, mouse). May occasionally reach with hands and arms. Must have the ability to look at a computer screen for extended periods of time.
            • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
              About Djo Global

              DJO Global is a leading global developer, manufacturer and distributor of high-quality medical devices that provide solutions for musculoskeletal health, vascular health and pain management. Our products address the continuum of patient care from injury prevention to rehabilitation after surgery, injury or from degenerative disease, enabling people to regain or maintain their natural motion. Our products are used by orthopedic specialists, spine surgeons, primary care physicians, pain management specialists, physical therapists, podiatrists, chiropractors, athletic trainers and other healthcare professionals. In addition, many of our medical devices and related accessories are used by athletes and patients for injury prevention and at-home physical therapy treatment. Product lines include rigid and soft orthopedic bracing, hot and cold therapy, bone growth stimulators, vascular therapy systems and compression garments, therapeutic shoes and inserts, electrical stimulators used for pain management and physical therapy products. Our surgical division offers a comprehensive suite of reconstructive joint products for the hip, knee and shoulder. Our products are marketed under a portfolio of brands including Aircast -, Chattanooga, CMF---, Compex -, DonJoy -, ProCare -, Exos---, Dr. Comfort -, DonJoy Performance - and DJO - Surgical.

              For Additional Information On The Company, Please Visit

              DJO is a growing subsidiary of diversified technology leader Colfax Corporation

              EOE AA M/F/VET/Disability

              All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of race, religion, color, national origin, sex, protected veteran status, disability, or any other basis protected by federal, state or local laws.

Keywords: DJO, Trenton , RCM Quality Control Representative, Other , Trenton, New Jersey

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