• Director-Revenue Integrity

    Location US-TN-MEMPHIS
    Posted Date 2 months ago(7/8/2019 1:38 PM)
    Position Code
    12251
    Status
    Regular Full-Time
    Department
    HS Central Bus Off
  • Overview and Responsibilities

    This position will have a specific focus on revenue integrity teams with the goal to enhance effectiveness of patient net revenue realization and minimize revenue leakage across the system.  This involves complete capture of patient revenue in every area that generates charges, management in relation to charging mechanisms and triggers, ensuring clean handoffs between clinical departments, strategic pricing, denials management, billing management and clinical operations relations.  In addition, the Director of Revenue Integrity will have a firm understanding of the Medicare IPPS, OPPS and ASC payment system.

     

    Essential Responsibilities:

    Missing charges, Pre-bill Edits, Rejections and Denials:  Oversees and provides direction to coordinators, extended team, special projects analysts, and consultants as necessary to support Revenue Integrity functions.

    • Responsible for held, rejected and denied revenue within Revenue Integrity work queues and ensuring daily, weekly, monthly and yearly revenue and production goals are met.
    • Monitors current and emerging reimbursement issues, regulations and reporting requirements. Critiques informational bulletins, journals, newsletters, and other sources and disseminates pertinent information and instructions to involved staff. Exhibits and maintains an understanding and application of CPT, HCPCS and ICD coding regulations and guidelines.
    • Evaluates, educates and resolves charge, CPT/HCPCS, modifiers, revenue code and unit discrepancies preventing third party insurance claims from clearing edits in billing system by applying CMS CCI, NCCI, MUE and other governmental billing regulations and payer guidelines to bills in advance of submission to third party payers. Advise Central Business Office (CBO) billing department in this regard.
    • Develops claim logic enhancements for revenue recovery, cash acceleration and integrity of editing system.

     

    Charge Description Master: Oversees the development, implementation and maintenance of the standard system charge description master (CDM) in accordance with policies and procedures.

    • Ensures compliance with federal, state and local regulations governing patient chargeable and performs revenue analysis and education.
    • Monitors compliance initiatives related to CDM data.
    • Tracks and remediates regulatory compliance investigatory activities and published findings correlated to CDM information.
    • Serve as are source for compliance information on regulations applicable to healthcare providers.
    • Interacts with leadership, department Directors and regional facility staff members regarding CDM compliance and related financial issues.
    • Meets with department Directors, staff, and/or physicians regarding new program and procedure developments, and validation of inactive codes.
    • Critiques informational bulletins, journals, newsletters, and other sources and disseminates pertinent information and instructions to involved staff. Exhibits and maintains an understanding and application of CPT, HCPCS and ICD coding regulations and guidelines.
    • Exhibits the ability to understand or analyze knowledge of billing systems and order entry interfaces with respect to implementation of a standard CDM.
    • Takes initiative to identify system problems and participate in the development of solutions to systems for improvement to billing functions.
    • Acts as Team Leader and/or Project Director for special projects related to CDM data, reimbursement, edit and rejection reductions and regulatory issues.

     

    Pricing (CDM and physician fee schedules): Management and accountability for fee schedule and CDM prices. Research, analyze, and recommend fee structure and derivation methodologies for the Senior Leadership Team to support.

    • Implement prices and maintain pricing when new procedures/supplies/studies/etc. are introduced throughout the year.
    • Coordinates the addition and deletion of CDM charges with Baptist One Care professionals and department personnel to prevent charge errors.
    • Adherence to contracted payer guidelines and policies with regard to patient care charging, third-party payer contracts, fee profiles, and reimbursement requirements for commercial health plans, state and federal programs.
    • Develop tools, processes, accountabilities for all pricing decisions. Document the processes and accountabilities.
    • Responsible for achieving strategic pricing net revenue targets as outlined in Baptist Memorial Health Care annual budget.

     

    Supervisory and Leadership Responsibility: Develops and oversees strategic vision and on-going enhancement of the Department through planning and execution.

    • Leads the organization through changes to meet new industry, internal or governmental requirements.
    • Takes initiative to identify system problems and participate in the development of solutions to systems for improvement to billing functions.
    • Communicates and interacts with senior leadership regarding initiatives, outcomes, successes and barriers.
    • Provide leadership, feedback, coaching, counseling, guidance and direction on management of Claim Edits, missing charges, CDM, fee schedules, charge capture, pricing and denials.
    • Assign, distribute, review work assignments ensuring timely and accurate completion.
    • Monitor deadlines.
    • Evaluate work performance through timely performance appraisals and identifying strengths and weaknesses.
    • Assist as a team member in the development, implementation and maintenance of internal controls and policies to maintain sound billing practices.
    • Evaluate needs by providing tools and training, as needed. Provide occasional feedback and regional representation for CDM-related National initiatives.

    Qualifications

    Basic Qualifications: (Required)

    Experience

     

    Minimum five (5) years of experience with facility and professional services billing, edit, rejections charge capture and CDM experience, (regulatory compliance, billing rules and regulations, maintenance, auditing, internal controls, and pricing).

     

    Education

    Bachelor's degree in health care financial management, business or related field OR four (4) years of experience in a directly related field

    High School Diploma or General Education Development (GED) required

     

    License, Certification, Registration

    N/A

     

    Additional Requirements:

    • Exposure to patient billing and accounts receivable system processes
    • Up to date working knowledge of Medicare billing regulations
    • Up to date working knowledge of medical coding rules and regulations
    • Detailed knowledge of revenue cycle work streams and revenue flow
    • Understanding of Industry specific terminology
    • Revenue cycle process management
    • Significant systems expertise
    • Working knowledge of current Medicare, Medicaid and other regulatory billing guidelines and requirements
    • Comprehensive experience with facility and professional billing requirements

     

    Preferred Qualifications:

     

    Minimum ten (10) years of experience with facility and professional services billing, charge capture and CDM experience, (regulatory compliance, billing rules and regulations, maintenance, auditing, internal controls, and pricing)

    Minimum five (5) years of experience as a CDM/Charge Capture Director in a large hospital system

    Leadership experience with patient billing and accounts receivable reduction practices

    Experience with Medicare billing regulations with a strong understanding of compliance requirements

    Master's degree in health care finance, business or related field

    Registered coder (CPC or CCS)

    Professional affiliation with the American Health Information Management Association (AHIMA), the Professional Association of Healthcare Coding Specialists (PAHCS) or AAPC

    Leadership position in an integrated health system

    Significant systems expertise with Epic

     

    Conditions of Employment:

     

    Baptist Memorial Health Care Corporation Director of Revenue Integrity manages a significant volume of business and operations across multiple locations. Work priorities shift in response to fluctuating demands. Full time schedules are assumed to be at least 40 hours, however, incumbents are expected to remain flexible to accommodate the unit's goals and mission, and to work beyond their normal schedule when necessary. While this role will primarily be based in an office environment, there will be exposure to clinical areas and operations. Ability to provide transportation to travel as required to accomplish the goals of the unit.

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