Revenue Integrity Coordinator

The Revenue Integrity Coordinator (RIC) is responsible for the identification, implementation, and monitoring of results for all revenue integrity-related activities in accordance with department policy. This includes working with team members to identify causes of denied, rejected, or underpaid claims. The RIC will act to correct errors by making appropriate referrals that will result in the protection of potentially lost revenue. The RIC will track and report causes of denied, rejected, or underpaid claims and work front end/concurrent/and retrospective cases for authorizations. The RIC will lead the team to retrieve, enter, and/or disseminate data to receive authorization on concurrent and retrospective cases. The work of the RIC will include providing information, through team reporting, to the appropriate individuals to facilitate performance improvement throughout the DCH System. The RIC role will provide oversight of the team's focus on preventing and reversing denials.

• Develops detailed knowledge of and drives the focus and goals of Utilization Review (UR)
• Retrieves and disseminates clinical data to third-party payers for authorization/certification of hospital level of care for front end/concurrent and retrospective certifications
• Refers adverse outcomes from third-party payers to appropriate members of the UR team
• Documents data in third-payer payer systems allowable within the revenue integrity skillset
• Documents certification data in Care Management and Business Office systems
• Works with the DCH financial counselors and registration to identify correct/accurate payer source
• Provides orientation, direction, and ongoing mentoring/coaching of the Care Coordination Clerk (MOONs; IMMs; Condition Code 44’s, Kepro Requests for Medicare appeals, entering moms & babes on JIVA & MIDAS, etc)
• Identifies opportunities for improvement related to denial management and report outcomes to the URM at least monthly
• Maintains accuracy of inpatient and outpatient working spreadsheet to include posting of payment, payment date, payer, and action performed
• Works within established processes of UR to identify denied/rejected/underpaid claims
• Performs interventions, appeals, and appropriate referrals to protect and collect potentially lost revenue by following up on inpatient and outpatient interventions and appeals to include calling insurance companies, physician’s offices, patients, and related DCH departments
• Maintains spreadsheet of criteria utilized by payers to deny claims and oversees this document
• Provides oversight for authorizations and denials and forwards to Medical Records
• Assists UR Manager in developing strategies for overturning appeals and reversing denied claims
• Applies critical thinking skills and knowledge to each claim to prioritize and perform interventions to maximize revenue protection within timely filing
• Ensures that communications are maintained regarding revenue integrity with all involved departments
• Supports the team through follow-up on inpatient and outpatient appeals and interventions
• Utilizes Expanse, Cortex, Quadax, Midas, and eFR software for reports and information related to denials
• Attends departmental meetings and assists the URM in educating the UR team on denial prevention
• Participates in annual departmental project and assists in leading the team in UR denial prevention
• Assists URM to arrange team meetings and may be responsible for minutes as necessary/requested
• Maintains performance, patient and employee satisfaction, and financial standards
• Adheres to DCH Behavioral Standards including creating positive relationships with patients/ families, and colleagues
• Provides level of care reports to Medical Records
• Provide backup clerical support as needed
  
  
  

DCH Standards

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Mission, Vision, and Values including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.
• High School graduate or equivalent with some college preferred.
• Minimum of two (2) years of combined experience with registration, scheduling, insurance verification, Utilization Review and patient collections.
• Strong organizational and computer skills are required.
• Must have previous experience working with multiple department heads in an effective manner and be able to do so in stressful situations.
• Knowledge of medical terminology is required.
• Ability to work, plan, and coordinate registration and scheduling functions within one cohesive unit
• Ability to develop and interpret computer-generated charts, graphs, and reports.
• Must be able to read, write legibly, speak and comprehend English
  
  
  

WORKING CONDITIONS

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals
  
  
  

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.