Revenue Integrity Specialist

Essential Duties and Responsibilities:

• Processes Cerner work queues, processes and enters charges for charge capture supported area/department using applicable documentation, follows up on all incomplete and inaccurate charges and makes prompt corrections utilizing coding expertise of CPT, HCPC, and ICD-10 codes.
• Help resolve complex claim edits and coding issues to ensure proper billing and reimbursement of accounts.
• Identifies workflow best practices for accurate and timely billing and follow up of all claims.
• Utilize Craneware for chargemaster maintenance, potential changes and support for clinical departments on questions and yearly updates to billing regulations.
• Utilizes reconciliation processes to ensure entered charges match documentation in medical record and assigns coding to entered charges utilizing coding expertise of CPT, HCPC, and APC Codes.
• Acts as a liaison between clinical departments and the revenue cycle.
• Collaborates with and serves as an expert resource for Department Managers, HIM, Patient Financial Services and end users to identify and resolve coding and billing issues to reduce denials. Communicates effectively to provide continual education and training for end users regarding coding, billing, and charge capture issues.
• Ensure the Charge Master is maintained/updated, and changes are made in accordance with Medicare and insurance guidelines.
• Build and maintain a database for managed care contracts.
• Effectively manages time, maintains a clean and orderly workstation. Prioritizes work activities consistent with department goals and can balance daily workload and several projects.
• Effectively monitors assigned work queues and workload, ensuring resolve of accounts in a timely and accurate manner.
• Identifies and communicate process improvement strategies, inaccuracies for resolution and corrective action to management in a timely and routine manner.
• Engages in implementing process improvement initiatives to enhance revenue opportunities.
• Maintain individual payer files to include up to date requirements needed for insurance claims to be successfully billed out for maximum reimbursement.  
• Assists with complex appeals for denied claims
• Stays current with CMS, AHA & state coding/charging & reimbursement guidelines.
• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order 
• Demonstrates ability to use EMR system to locate and upload medical record information
• Consistently reports to work at the scheduled time in a punctual manner and at the assigned job location.
• Regularly attend monthly staff meetings and continuing educational sessions as requested.
• Attends all required Safety Training programs and can describe his/her responsibilities related to general safety, department/service safety and specific job-related hazards.
• Follows the Hospital Exposure Control Plans/Bloodborne and Airborne Pathogens.
• Demonstrates respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment.
• Promotes effective working relations and works effectively as part of a department/unit team inter- and intra- departmentally to facilitate the department’s/unit’s ability to meet its goals and objectives.

Non-Essential Duties and Responsibilities:

• Perform other duties as assigned

Professional Requirements:

• High degree of understanding of payer policy guidelines.
• Proficient knowledge of Coding Rules and Regulations required (i.e. CPT, HCPCS, ICD-10, APC, and DRG) following coding/charging guidelines and policies.
• Working knowledge of Chargemaster set up and the role it plays in correct coding and billing.
• Excellent computer skills including Excel, Word, and Internet use
• Detail oriented with above average organizational skills
• Plans and prioritizes to meet deadlines
• Excellent customer service skills; communicates clearly and effectively
• Ability to multitask and remain focused while managing a high-volume, time-sensitive workload
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies.
• Conduct oneself as a professional in accordance with PRIDE values.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.

Job Requirements:

• High School Diploma required. College level classes in HIM, coding or finance preferred.
• Minimum 5 years prior hospital/medical billing or coding experience required.
• CPT, HCPCS, ICD-10 knowledge required. Coding certification through AAPC or AHIMA preferred.
• Knowledge of medical terminology required.
• Minimum 5 years of experience with insurance companies and government payers.
• Craneware experience or knowledge preferred.

Organizational/Core Competencies:

• Quality Service
• Team Work
• Communication
• Respect for Others
• Time and Priority Management