Revenue Integrity Specialist

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This position will review charge review, claim, and denial edits to ensure compliance with CCI, OCE, MUE claim edits and LCD & NCD billing rules, while maximizing reimbursement. Works with Revenue Cycle leadership to ensure ongoing development, testing, implementation, maintenance and operational optimization of Epic’s Revenue Guardian module and/or other related claim editing software. Monitors trends in billing edits to identify needs for retraining and optimization of the build of editing tools to minimize manual intervention and maximize compliance. Works through Revenue Cycle leadership to communicate training and optimization needs to clinical leadership, chargemaster committee, compliance, and related areas.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or equivalent.

EXPERIENCE:

1. Two (2) years of billing- revenue cycle experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in business or other healthcare related field or Health Information Technology graduate.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Manages payor and claim CCI, OCE, MUE, LCD and NCD edits in a timely, accurate and compliant manner.

2. Tracks edited accounts, correspondence, actions, and outcomes as well as coordination of activities and follow-up for payor and claim edits.  Reports trends to Revenue Cycle Leadership

3. Monitors, analyzes and reports on denials appeals and follow-up activities related to billing edits.

4. Provides assistance to departments regarding compliance with government regulations, when requested as it relates to claim edits.

5. Works with revenue cycle leadership, chargemaster committee, and clinical departments (when required) to ensure optimal charge capture for services provided.

6. Maintains up to date knowledge of payer policies and government regulations to ensure compliant and accurate billing processes.   Communicates relevant information to revenue cycle leadership.

7. Performs root-cause analysis for high volume edits to reduce the incidence of non-billable charges.  Works with technical Epic team to correct any technical error causing incorrect charge routing and clinical departments and/or HIM on missed charges.

8. Reports on the volume of claim edits to leadership with the goal of reducing the volume of edits occurring over time and to quickly identify any new claim errors that begin with updated policies.

9. Performs claims reviews ensuring that record documentation supports charges captured.

10. Provides support and assistance to Revenue cycle Leadership as needed.

11. Prioritizes work to effectively reduce volume and meet payer appeal deadlines

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent walking, standing, stooping, kneeling, pushing, lifting, grasping, and feeling are necessary body movements utilized in performing duties through the work shift.

2. Must be able to sit for extended periods of time.

3. Must have reading and comprehension ability.
 

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Exposed to high levels of stress and anxiety.
2. Experiences constant interruptions.

SKILLS AND ABILITIES:

1. Must be capable of using computers effectively.

2. Knowledge of medical terminology, ICD-10, CPT & HCPCS codes.

3. Analytical, critical thinking and clear, concise communication skills are required to interact effectively with all levels of management

4. Must be capable of using copier/fax effectively.

5. Good analytical skills including the use of Microsoft Excel and reporting tools.

6. Good communication skills and professional demeanor required.

7. Understanding of payor clinical reimbursement policies and government regulations.

8. Understanding of ACP/MPFS payment structures and other third-party payment methodologies.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

660 SYSTEM Revenue Integrity