Lead Revenue Integrity Specialist

POSITION SUMMARY:

The Lead Revenue Integrity (RI) Specialist works collaboratively in a team environment providing support to the Revenue Integrity team with the support of the Revenue Integrity Specialist (s). This position collaborates closely with clinical departments to educate staff and promote compliance with established charge capture and charge reconciliation policies and procedures and to ensure appropriate charge capture effectiveness. The Lead Revenue Integrity Specialist identifies and recommends opportunities for improved standardization and consistency of Charge Capture processes throughout the IDN. The Lead Revenue Integrity Specialist responsible for communicating regularly with revenue reimbursement, decision support, financial reporting, hospital departments, health information management (HIM), clinicians, and others to ensure compliance of all regulations and optimal effectiveness of revenue integrity reporting.

The Lead Revenue Integrity Specialist uses reporting tools, data extraction, and analysis to understand revenue and compliance risks and opportunities with significant impact on Health First and conveys these risks to leadership. Monitors Revenue Integrity specific work queues, including Revenue Guardian checks, and charge review work queues among other duties. Supports Revenue Integrity-related troubleshooting needs and disseminates best practices and lessons learned across service line teams. The Lead Revenue Integrity Specialist actively communicates and presents pertinent information as well as collaborates with the Revenue Integrity Specialist (s) and reports to the Revenue Integrity Manager.

PRIMARY ACCOUNTABILITIES:

1. Monitor revenue departments’ adherence to charge reconciliation processes and metrics measured by key performance indicators.

2. Oversees audits of clinical departments, guiding and monitoring Revenue Integrity team members in assigned areas. Review findings with departmental leadership, focusing on documentation standards and recommendations for improvement.

3. Identify charge trends, conduct focused reviews of specific departments, and present findings and recommendations for improvement.

4. Lead annual, quarterly, and regular Customer Data Management (CDM) maintenance activities.

5. Review changes in Current Procedure Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS), and revenue codes for accuracy, compliance with applicable billing guidelines, and optimization of reimbursement.

6. Develop, deliver, and revise integrity education and training programs in coordination with the revenue integrity manager.

7. Monitor, investigate, and resolve revenue integrity concerns and violations reported in their area and provide any necessary follow-up.

8. Monitor national, state, and local information to keep current with applicable regulatory and legislative changes and tailor the revenue integrity program accordingly.

9. Communicate CDM maintenance activities to clinical departments and information systems staff to implement necessary changes that affect charge identification, capture, reconciliation, and claim processing.

10. Conduct training and orientation in group and one-on-one settings and lead in-service presentations for nursing, physician, and clerical staff to address audit findings and regulatory updates.

11. Work with Charge Review Analysts and Specialists to ensure accurate and timely responses to departmental inquiries. Collaborate with Denials or Appeals and Coding teams to drive results through the revenue cycle.

12. Maintain up-to-date knowledge of Medicare/Medicaid billing practices and apply CMS rules, Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), and other regulatory guidelines to ensure compliance.

MINIMUM QUALIFICATIONS:

Education: Bachelor’s degree in health information management, Business Administration, Finance, Accounting, or a relevant field.

• Work Experience: Five (5) years in healthcare field.
• Licensure: None
• Certification:

• Epic Resolute Billing certification.
• Charge Router certification.

Skills/Knowledge/Abilities:

Extensive knowledge of revenue cycle processes and hospital/ medical billing to include CDM, UB, RAs and 1500.

• Extensive knowledge of code data sets to include CPT, HCPCS, and (Internal Classification of Diseases (ICD)10.
• Extensive knowledge of NCCI edits, and Medicare LCD/NCDs.
• Extensive understanding of reimbursement theories to include Diagnosis Related Group (DRG), Outpatient Prospective Payment System (OPPS) and managed care.
• Extensive working knowledge of health care compliance. Extensive understanding of medical terminology, anatomy, and physiology along with clinic department activities
• Excellent communication, presentation, organizational, analytical, and critical thinking skills.
• Must approach problem solving challenges independently, have strong attention to detail and enjoy working in a fast paced, collaborative team-based environment.
• Advanced knowledge of Microsoft applications including Word, Excel, Visio, Outlook, and PowerPoint.

PREFERRED QUALIFICATIONS:

• Work Experience: Previous experience with Epic Electronic Health Record (EHR).

PHYSICAL REQUIREMENTS: Sedentary

• Majority of time involves sitting or standing; occasional walking, bending, stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined; on site or remote.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.