Revenue Integrity Manager, Full-Time (Hybrid/Remote)

GENERAL SUMMARY OF DUTIES:

The Revenue Integrity Manager plays a leadership role in improving revenue results by taking a global view of clinical and financial processes, functions, and interdependencies from the provision of patient care to final bill generation, improving the hospital’s revenue cycle while also managing retrospective clinical denials. The position involves improving revenue cycle procedures and accountability, reimbursement analysis, retrospective denial management, and making sure of charge description master (CDM) compliance and accuracy. This is a highly visible position that combines clinical, business, and regulatory knowledge to reduce financial risk.

REQUIREMENTS:

• Bachelor’s degree in nursing
• Registered nurse (RN) with an active license upon hire
• Five years of experience in a hospital setting (surgical hospital preferred)
• Experience with insurance reimbursement methodologies required
• Familiarity with the charge description master file required
• Experience with providing education to providers and other staff regarding documentation and coding
• Excellent organizational, interpersonal, telephone, documentation, and communication skills

ESSENTIAL FUNCTIONS:

• Work and analyze billing errors and denial data to identify root causes. Executes work plans to correct identified deficiencies.
•  Participates in internal and external contracted payor discussions and negotiations regarding clinical coding and charging standards.
•  Acts as primary revenue cycle liaison for the most complex clinical departments and practices and acting with a high degree of autonomy
•  Provides education to providers regarding documentation, coding, and denial trends
•  Analyzing department billing procedures, researching billing compliance issues
•  Educates clinicals departments on departmental charge reconciliation to assure accuracy and monitors this accuracy.
•  Auditing patient accounts to ensure billing compliance through charge reconciliation
•  Stays current with contracted reimbursement methodologies and coverage guidelines
•  Aids in establishing and implementing policies and procedures to ensure compliance with Medicare Billing Guidelines
•  Initiates clinical discussions and written communications with surgeons, nurses, case managers, and other staff based on reviews of Medicare fiscal intermediary bulletins, CMS memorandums, and commercial payment and clinical policies
• Perform reviews and makes required updates related to Charge Description Master (CDM) maintenance.
• Participates in complex projects related to revenue cycle initiatives.
• Develops, maintains, and implements Revenue Integrity and CDM Management policies, procedures, and training materials
• Identifies trending on denied claims, root causes of denials, and collaborates with the appropriate departments to make recommendations for improvements.
• Drafts and submits clinical appeal letters and submits documentation required for appeal resolution
• General understanding of medical necessity criteria (i.e., Milliman/InterQual), Medicare coding rules, authorizations, insurance verifications, and accepted coding and claims payment standards
• In partnership with the Business Office, evaluates, resolves, and remediates billing edits, exceptions, and denials, resulting from charge issues, NCCI or OCE edits and medical necessity

PHYSICAL DEMANDS:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job the employee is often required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools, or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
• The employee must be able to lift and/or carry over twenty pounds on a regular basis and be able to push/pull over twenty-five pounds on a regular basis.
• The employee must be able to stand and/or walk at least five hours per day.

WORK ENVIRONMENT:

•  Hybrid