Revenue Integrity Analyst - Reimbursement (PRN)

PURPOSE OF THIS POSITION

The primary purpose of the Revenue Integrity Analyst position is to support optimal and compliant revenue capture for accounts that generate a facility or professional claim by the Revenue Cycle Division. Primary functions include performing quality and productivity audits on functions performed by the billing, revenue integrity, and credit and collections teams to ensure quality and compliance. Promote and maintain relationships with insurances to resolve outstanding claims issues and identified systematic issues which result in delayed reimbursement. Works with clinics and departments to help improve process which result in claim submission delays and/or claim denials.  Completes reports for submission to support regulatory requirements and to support the functions of the Revenue Cycle Division. Provides education to both internal and external teams to improve revenue cycle functions and processes.

JOB DUTIES/RESPONSIBILITIES

• Duty 1:  Perform focused and random internal audits on the functions of the Revenue Cycle Division (i.e., billing, denials management, posting, financial assistance) to ensure compliant practices, which result in accurate reimbursement and patient balances.  The primary emphasis is on accounts which generate a facility or professional claim by the Revenue Cycle Division.
• Duty 2: Document identified opportunities, create reports/dashboards to trend and/or analyze data, establish and monitor key performance indicators. Tracks and provides up-to-date metrics. Prepares timely and accurate reports for presentation to clinical departments, leadership, and key stakeholders. Provides recommendations to clinical areas on processes which support clean claim rates, denial reduction, and timely reimbursement.
• Duty 3: Participates in external audits (i.e., RAC, insurance) that may impact reimbursement.  Provide support to Corporate Compliance in audit processes as it relates to functions that support claim submission and reimbursement. 
• Duty 4 Maintains relationships with insurance provider representatives, leads regularly scheduled meetings with the provider representative to work through the resolution of outstanding claims. Works with the denials management specialists and billing specialists to identify claims which need escalated to the provider representative.  Works with Denials Prevention Analyst to identify high trend-high financial impact systematic denials. Collaborates with the managed care department for assistance in escalating claims, when needed.
• Duty 5: Works closely with managed care to stay current on contract terms and policy updates. Reviews payer newsletters, payer alerts, and monitors payer policies.  Works with Experian Contract Management to update system build to accurately identify underpayments. Communicates with affected areas on process changes which may be required because of payer policy updates to ensure compliance and to prevent an impact on the clean claim rate, denials, or other delays in reimbursement.
• Duty 6: Partner with other key areas to support a clean, accurate, and compliant claim. 
• Duty 7:  Assists departments and/or facility with the implementation of new service lines as it directly relates to CPT/HCPCS coding, documentation, and charges. Reviews NCD’s and LCD’s to provide medical necessity information as determined by CMS or CGS. Quantifies and provides comparative data to understand impact of how changes / additions may financially impact the department or facility and/or the charging processes.  Communicates and assist departments to implement changes related to charge structure and/or processes, as appropriate.   
• Duty 8:  Act as an administrator for payer websites to manage access for members of the Revenue Integrity Department, and any external vendors, to ensure an efficient workflow. Ensures that access is removed when it is no longer required.   
• Duty 9: Review, approve, and post adjustments based upon the Denial Write-Off Approval Levels. Use the adjustment tracker to identify any opportunities in trends and provide feedback and education to adjustment tracker users.
• Duty 10:   Completes audits and complies reports for timely submission related to regulatory requirements in areas that support the Revenue Cycle Division.  (i.e., Medicare Credit Balance reporting, HCAP, J series, COVID tracker, No Suprises Audit, Discharge Status, etc.)
• Duty 11: Create and present (in person and virtually) education to providers, clinical departments, and provider office supporting staff to support successful charge practices, including training on tools/resources available (e.g. Craneware, websites, etc.). Provide orientation materials, and directly communicate with, new providers on charge capture and documentation requirements. 
• Duty 12:  Demonstrate superior understanding of federal, state and third-party charging guidelines to identify required changes to CDM and potential reimbursement impacts.  Stay current on quarterly and yearly OIG work plans. Analyze revisions to coding and billing regulations, including OPPS and IPPS as appropriate revisions, by resourcing credible references (i.e. CMS website, Craneware, publications, professional contacts, reliable internet sources, seminars, etc.).
• Duty13:  Coordinates and/or participates in system testing as a result of upgrades, changes, enhancements, new application implementations, etc. that may impact charge capture and/or charge data flow. Serves as the Superuser for the Craneware application (facility and professional toolkits); includes provide training and remain current on system features and functionality.
• Duty14: Assists in developing revenue integrity-related departmental, division and/or organizational policies and procedures for recommendation and approval, as necessary. Maintain policies on MCN.
• Duty15: Regularly attends and actively participates in in-services, organizational meetings.  Utilize lean management tools (e.g. huddles, idea boards, A-3 process, mapping, etc.) and continuing education programs as offered in order to remain current with organizational and industry changes and best practice.  Communicate and disseminate information to other departments as applicable.

REQUIREQ QUALIFICATIONS

• Associate’s degree in a related field including, but not limited to, health information, business, healthcare finance or related clinical profession required or 5+ years’ experience from which comparable knowledge and abilities have been acquired.
• Three (3)+ years direct professional and/or facility coding or billing experience.
• CCS, CCS-P or CPC certification required within 6 months of hire date.
• CPMA (Certified Professional Medical Auditor) required or achieved within 12 months of hire date.
• CPT/APC/HCPCS and ICD/DRG coding and reimbursement concepts knowledge required. 
• Knowledge of revenue cycle workflows with emphasis on clinical documentation, charge capture, coding and billing required. Knowledge of charge flow and relationship to other functions such as General Ledgers, Supply Chain, clinical documentation and charge trigger points and other interdependencies. 
• Regulatory compliance and reimbursement methodologies knowledge required. Ability to research, review, analyze, and interpret Federal, State and Local billing regulations required.
• Proven competence in utilization of computer applications; including Microsoft Office applications, 3M, with moderate-advanced skills in Excel required; experience with electronic health record systems required.
• Ability to compile, analyze and effectively present data and complex information in an informative and meaningful way to a variety of audiences, including leadership.
• Ability to effectively present/educate all levels of the organization and small and large audiences (e.g. coders, clinical departments, medical staff, executive staff, etc.)
• Ability to manage complex issues and manage multiple tasks/projects. Excellent organizational and time management skills; detail oriented and follow through. Self-directed.
• Strong problem-solving, research and analytical skills required.
• Familiarity with utilization of computers and commonly used applications, including Microsoft Office Suite, (Windows, Excel, PowerPoint, Teams, Word, Outlook), 3M Encoder, electronic health record, internet required
• Positive service-oriented interpersonal and communication (written and verbal) skills required. Ability to effectively present and interact with all levels of the organization, including senior leadership.

PREFERRED QUALIFICATIONS

• Bachelor’s degree
• RHIA or RHIT
• Certified Professional Biller (CPB) certification
• Certification in Healthcare Revenue Integrity (CHRI)
• CPFSS certification

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.