Revenue Integrity Analyst

Position Summary

The Revenue Integrity Analyst (RIA), reporting directly to the Chief Revenue Officer will serve as a critical leader of the revenue cycle operation team and be responsible for performing in-depth analysis of patient clinical and billing data to identify contractual, documentation, and denial prevention opportunities with the focus on creating process improvement initiatives. Develops and implements action plans for denial prevention based on root cause analysis findings. Promotes revenue cycle operational efficiency, data integrity and compliance with billing and regulatory guidelines. Responsible for working complex denial coordination with intra-team members to identify root cause. Performs audits and collaborates with intra and inter-departmental teams on compliance, education, accuracy in charge capture and improvement in the revenue cycle processes as identified through revenue cycle audits and root cause analysis. Works closely with clinical areas to effectively document services performed and understands relationship of documentation, medical necessity, coding and charging for all services provided. Coordinates communication between Provider and Payer’s regarding underpayments related to contractual issues and/or denials. Monitors Inpatient Denial inventory to ensure maximum reimbursement is achieved. Completes assigned reports timely and accurately

Primary Position Responsibilities

1. Manages/Reconciles Clinical Denial worklist, ensuring inventory is actively being work while communicating findings to the Director of UR and Chief Revenue Officer which includes reviewing status within the Cobias system.

2. Performs ad hoc consultative research and coordination on current issues of Revenue Cycle regulatory risk including medical necessity denials; identifies a framework of continuous improvement to accomplish programmatic goals; facilitates meetings both internal and external; works collaboratively with system compliance leadership to coordinate and manage RAC and payer audit appeals. Identifies barriers and implements corrective action measures in partnership with leaders to ensure positive outcomes. Provides ongoing guidance, training and support to practices and departmental Revenue Cycle staff. Works collaboratively leadership and health professionals to accomplish organization and Revenue Cycle goals.

3. Responsible for complex and specialized assignments requiring the application of deep analytical and practical guidance and direction. Serves as a technical resource providing seasoned and specialized knowledge and interpolative and adaptive thinking in response to a variety of situations and challenges. Maintains an understanding of regulatory and payer changes to assure correct charging and billing requirements are met and provides recommendations as necessary.

4. Serves as the Liaison between PFS and Payer Contacts. Creates monthly Excel Payer logs utilizing several spreadsheets and consolidating them into 1 Payer log. Reviews information contained on log and has final approval on submission to Payer. Reviews Contracts and compares against third Party Software (PMMC) to ensure contractuals are correct and makes recommendations as necessary. Manages downgrade billing process, utilize tools, software and reports provided.

5. Performs other revenue optimization activities as appropriate, which includes providing education, process improvement, ongoing assessment and resolution of root cause issues resulting in reduced or slower cash flow.

6. Conducts Audits on Denials (Outpatient and Inpatient) identifying root cause issues along with providing process improvement recommendations. Works with ancillary teams and providers to develop processes to prevent future denials. Coordinates denials and appeals and/or reconsideration requests on clinical, coding and technical denials between hospital ancillary depts. and PFS

7. Communicates and interacts with all levels of personnel across the organization. Provides consultation, leadership and managerial direction in the delivery of small to mid-size project initiatives/teams for an operational area of revenue management. Exhibit strong professional customer service in daily interactions. Other duties as warranted

Qualifications

Minimum Education :

Required:

Bachelor Degree of Arts, Business, Finance or Education along with relative experience

Preferred:

None

Minimum Years of Experience (Amount, Type and Variation) :

Required:

2-5 years’ experience in a Revenue Integrity role.

Knowledge/ experience with DRG/APC payment methodology/ Contract Analytics.

Thorough knowledge Back End Revenue Cycle Processes for Acute Care

Preferred:

None

License, Registry or Certification :

Required:

None

Preferred:

Certified Revenue Cycle Specialist - Institutional (CRCS-I) or Certified Revenue Cycle Specialist - Professional (CRCS-P) through AAHAM.

Knowledge, Skills and/or Abilities :

Required:

Proficient in Excel, Word. Excellent Writing/Communication required.

Experience in Payer Contracting and rate calculations required.

Considerable knowledge and experience supporting and developing reporting and analytics for research, process improvement/change management support and specific revenue management function. Ability to develop appropriate methods to collect, analyze and report data

Experience working with UR systems and Denials required. Proven track record in process improvement.

Knowledge of Ambulatory Payment Classification (APC), and Outpatient Prospective Payment System (OPPS) reimbursement structures and prebill edits including Outpatient Coding Edits (OCE)/Correct Coding Initiative (CCI) edits and Discharged Note Final Billed (DNFB).

Exceptional organizational skills and ability to prioritize and manage multiple functions and responsibilities simultaneously.

Experience with post payment audits and with coding, clinical and technical denials is required.

Excellent interpersonal, verbal and written communication and organizational abilities. Accuracy, strong analytical skills, attentiveness to detail and time management skills are required.

Preferred:

None

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).