(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...

in good standing with the relevant State licensing authorities; must possess a medical
license from an accredited Medical School.
NOTE: As federally mandated, the RAC must hire a minimum of one full-time Medical
Director for the RAC Program contract.
c. Audit Manager: Individual with relevant experience in Medicaid claims reimbursement,
policies and regulations and auditing techniques and procedures, including, but not
limited to, Medicaid provider cost reports; working knowledge of government auditing
standards is valuable. Certified as a Fraud Investigator or other similar credentials are
preferred.
d. Medical Review/Utilization Manager: Individual with recent and relevant supervisory
experience in medical utilization review. Education (Required): The Medical Review
Manager shall possess a bachelor’s degree in nursing and/or social or health service
with an active Registered Nurse license.
e. Statistician: Individual with relevant and recent experience in the use of statistics to
support corporate business information needs; experience in the use of statistics to
detect fraud, the use of fuzzy logic, the development of mathematical models, neural
networks and data mining methods of analysis. Knowledge of health care information
and claims data (ICD-9 codes, physician specialty codes, HCPCS codes for the
appropriate year of review, survey, certification data and ICD-10, when implemented,
etc.) is also considered valuable.
f. Technical Point of Contact for Information Technology: Individual with relevant IT
experience who can initiate, focus, and facilitate ongoing communications and
information exchange with regard to telecommunications.
g. Ensure clinical staff are experienced or knowledgeable in Texas Medicaid claims
payment processes, medical documentation review and recovery auditing. Whenever
performing complex coverage or coding reviews for specialty providers (i.e., reviews
involving the medical record), the RAC shall ensure that coverage/medical necessity
determinations are made by specialty RNs or therapists and that coding determinations
are made by certified coders. The RAC shall ensure that no nurse, therapist or coder,
specialist or non-specialist, reviews claims from any provider who was their employer
within the previous 12 months. RAC shall maintain and provide documentation upon any
provider’s request for the credentials of the individuals making the medical review
determinations.
h. Provide list of administrative staff that will coordinate all audit activities with HHSC.
i. Provide credentials of clinical and administrative staff to HHSC, as requested.
2.3.9. Reporting (Claims Based Approach)
a. Report and refer all potential/suspected fraud cases to HHSC OIG in a timely manner.
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