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Director, Revenue Integrity & HIM

Company: Connecticut Children's Medical Center
Location: Hartford
Posted on: November 24, 2022

Job Description:

SUMMARYPosition SummaryThe Director of Revenue Integrity & HIM serves as a mid-revenue cycle subject matter expert and thought leader in the areas of HIM operations, professional and facility coding, utilization review, denials management, charge capture and revenue reconciliation. In this role, the Director will be responsible for the following:Provide a strategic roadmap for delivering best practice hospital and physician clinic mid-revenue cycle revenue integrity functions.Manage daily workflows for revenue integrity specific mid-revenue cycle functional duties and areas of responsibility.Work closely with clinical, ancillary, compliance and finance department management teams to ensure compliance and revenue integrity with government, payer, and charge capture requirements.Manage/Maintain Revenue Integrity specific claim edits.Monitors and manages charge capture audit results, conducts analysis as needed, assists clients with corrective action plans and provides education to clinical and ancillary departments.Monitoring and managing APC, EAPG errors, NCCI/OPPS Edits, LCDs, NCDs and RAC-related issues/denials.Assisting in the implementation of charge related functions and workflows that impact charge integrity and compliant, accurate revenue capture.Manage/Maintain coding & CDI specific work queues and processes.Manage/Maintain utilization review processes to ensure correct patient status capture.Other job-related duties as assignedDUTIES AND ROLE RESPONSIBILITIESThe Director of Revenue Integrity & HIM provides revenue cycle support services through efficient review and timely resolution of assigned Medicaid, Medicare and third-party payer accounts that are subject to pre-bill claim edits and claim denials. Typical daily duties for this position include:Responsible for managing the daily resolution of assigned claims with applicable Revenue Integrity pre-bill edits and/or specific Revenue Integrity holds. Tasks associated with this work include resolving standard billing edits such as:Correct Coding Initiative (CCI)Medically Unlikely Edits (MUE)Medical Necessity editsOther claim level edits as assignedAs needed, review clinical documentation and diagnostic results as appropriate to validate and apply applicable ICD-10, CPT, HCPCS codes and associated coding modifiers.Responsible for managing the daily resolution of assigned claims with Revenue Integrity specific denials.Ensures that RI specific coding and billing practices are following Federal/State guidelines and approved hospital policies and procedures by utilizing various types of authoritative information.Maintains current knowledge of Medicare, Medicaid and other third-party payer billing compliance guidelines and requirements.Communicates regulatory changes in a timely manner to clinical, ancillary, compliance and finance departmentAs required, supports the CDM Chargemaster with focus on regulatory coding requirements, compliance, revenue integrity, standard naming conventions and pricing integrity.As applicable, recommend and/or coordinate updates to the CDM as it pertains to NCCI/OPPS error edits in the client's claims processing system ('claims scrubber').Coordinate education activities to clinical, ancillary compliance and finance department stakeholders regarding compliant use of CPT codes, HCPCS codes, revenue codes, and modifiers.Reviews reports daily to identify charging/ late charging/coding/CDM potential compliance issues and/or revenue opportunities; conducts analysis to correct identified charge capture issues; reports the revenue impact differential for issues identified, implemented, or corrected.Monitors charge capture/reconciliation practices in hospital and physician clinic departments, reports findings to client stakeholders, and if needed, provide education to staff responsible for charge capture.Reviews data reports/spreadsheets as necessary or requested; writes real-time and ad hoc reports as needed or requested; conducts research to resolve identified potential patient billing and account issues; initiates account/charge corrections as needed.Performs periodic random and focused charge capture review audits for departments with identified charging/billing issues.Assist with mid-revenue cycle specific projects to implement appropriate CDM charge structures to support revenue integrity and charge capture compliance.Other job-related duties as assignedKnowledge and skills required:Working knowledge and experience in ICD-10, CPT and HCPCS Level II Coding.Knowledge, understanding and proper application of Medicaid, Medicare and third-party payer UB-04 billing and reporting requirements including resolution of CCI, MUE and Medical Necessity edits applied to claims.Knowledge of current code bundling rules and regulations along with proficiency on issues regarding compliance, and reimbursement under outpatient grouping systems such as Medicare OPPS and Medicaid or Commercial Insurance EAPG's.Knowledge and understanding of hospital charge description master coding systems and structures.Excellent verbal and written communication skills due to direct interaction with senior management.Strong time management and organizational skills.Strong problem solving and financial analytical skills.Ability to interact professionally with all levels of employees.Improves technical skills through professional development efforts.Timeliness and accountability.Work Environment:Travel to client sites may be required.Minimal exposure to the risk of contagious and blood borne diseases.Occasional varying and unpredictable situations.Minimal exposure to accidents, injuries, illness.Subject to irregular hours.Professional work environment/ hospital.Requirements:Bachelor's degree in health care finance, Health Information Technology or related discipline or ten (10) years equivalent and related work experience required.Experience with EPIC EMR and related system functions strongly preferred.Prior experience in a large acute care hospital setting with multi-specialty physician group practice or faculty practice environment.

Keywords: Connecticut Children's Medical Center, Hartford , Director, Revenue Integrity & HIM, Executive , Hartford, Connecticut

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