Revenue Integrity Analyst

Revenue Integrity Specialist

Under general supervision, the Revenue Integrity Specialist is the operating muscle of the charge capture engine. Day to day, this individual reviews charge tickets (both paper scanned and electronic feeds from EHR) against clinical documentation, applies Omega charge capture guidelines to validate or correct the charge, reconciles charges to encounters, surfaces missed charges, and supports the dashboarding effort by feeding clean, categorized exception data upstream. The Specialist works across hospital and physician charging contexts, with a working understanding of CPT, HCPCS, ICD-10-CM, modifiers, revenue codes, and place of service implications.

Essential Job Functions

• Review paper charge tickets, electronic charge tickets (e-superbills), and EHR-driven charge feeds for completeness, accuracy, and adherence to charge capture guidelines.
• Maintain a clear, auditable documentation trail in the workflow tool, drafting exception notes to defend NCCI (PTP/MUE) and OCE modifier decisions for external auditor review.
• Validate CPT / HCPCS code selection against documentation; verify modifier appropriateness (25, 26/TC, 50, 51, 59 / X{EPSU}, 76/77, 91, 95, AS / AA / QX / QY / QK, GA / GY / GZ).
• Flag missing or mis-applied units, incorrect revenue codes, place-of-service mismatches, and date-of-service inconsistencies.
• Reconcile daily charge files against scheduled / completed encounters from EHR (Epic / Cerner / Meditech) — every encounter must have either a posted charge, a documented exception, or a defensible no-charge reason.
• Investigate variances within agreed turnaround time; raise tickets for system-level issues (interface failures, charge router rule gaps, incorrect EAP linkage).
• Apply CMS, NCCI, and client specific charge capture guidelines, including modifier driven bypass logic and outpatient OCE edits.
• Identify systemic charge capture defects (e.g., recurring infusion start/stop time gaps, recurring Mod 25 misuse on E/M with procedure) and escalate root cause to Lead with sample evidence.
• Categorize exceptions, denials-prevention findings, and missed charge recoveries using the standard taxonomy so revenue-integrity dashboards remain consistent across pods.
• Produce daily / weekly individual productivity and accuracy reports; participate in calibration sessions led by QA.
• Operate within HIPAA, HITRUST, and Omega information security policy; never share PHI outside designated channels.
• Cooperate with internal QA audits (sample-based, IQ/EQ) and respond to audit feedback with documented corrective action.

Key Success Indicators/Attributes

• Detail oriented under volume pressure – comfortable with repetitive review work without losing accuracy.
• Coachability – willing to absorb feedback from QA without defensiveness; uses calibration sessions to improve.
• Crisp written communication – exception notes are read by US revenue integrity managers; clarity matters more than length.
• Time discipline – meets daily TAT; flags blockers early rather than at end of shift.
• Confidentiality and ethical handling of PHI.
• Maintain courteous and professional working relationships with employees at all levels of the organization.

Supervisory Responsibility: No

Work Environment: This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and soft phones.

Physical Demands: While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work: This is a full-time position. Each employee's schedule must be between the hours of 6:00 AM PST to 9 PM PST, Monday through Friday with the specific schedule for each employee to be agreed upon by the employee's manager and the employee, taking into account the needs of the client. This position occasionally requires long hours and weekend work.

Travel: None

Required Education and Experience:

• 3+ years hands-on US revenue integrity, charge capture, or charge audit experience in a US healthcare provider or vendor environment.
• Bachelor's degree or combination of relevant experience with strong RCM tenure.
• Hands -on proficiency with at least one major EHR platform: EPIC (Resolute HB/PB), Cerner Patient Accounting, Meditech (Magic/Expanse), or Athena.
• Must fulfill one of the following qualifications: Pathway A – Active AAPC (CPC/COC) or AHIMA (CCS/CCS-P) certification. Pathway B – HFMA CRCR certification paired with at least 4 years of demonstrable depth in charge-capture, chargemaster, or charge-router operations.
• Working knowledge of payer guidelines and contracts, including experience in contract review, negotiations, or audit variance review across multiple payers.
• Intermediate Excel proficiency, including pivot tables, lookups, conditional formatting, and basic formulas.

Preferred Education and Experience:

• Familiarity with HFMA MAP metrics (e.g., % missing charges, charge lag).
• Ability to read and interpret Power BI or Tableau dashboards to track exception data.
• Prior exposure to multi-hospital or Integrated Delivery Network (IDN) environments where charging rules vary by entity.
• Exposure to charge router rule design (EPIC CRD), charge capture solutions like 3M/MModal/ Optum (formerly OptumInsight) charge capture intelligence.
• AAPC CPMA certification preferred.

Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. Employee may perform other duties as assigned.