Summary

With direction from the Patient Financial Services Director, the Revenue Integrity Specialist is responsible for performing audits of itemized charges versus the patient medical record and other applicable hospital documentation, assigning modifiers to appropriate claims, researching edited claims for medical necessity, and advising the revenue cycle staff of appropriate HCPCS codes and modifiers.  The Specialist works directly with revenue producing departments regarding lost charges, billing questions, proper coding and charging, education on appropriate charge capture and providing CDM support.  The Specialist reviews documentation on all Observation accounts for carve-out observation hours, extended recovery, and event management, spot checking accounts with random audits. 

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

Coordinate, supervise, and respond to various billing audits. Perform patient and payer requested audits in a timely manner. Perform random quality audits as schedule permits. Work and review a high volume of accounts assigned to Revenue Integrity Specialist work queues for charge review of all observation account documentation to charges, carve-out observation time from procedures, review documentation to charge code injection and infusion charges, and review of various charge audit. Ensure accuracy and integrity of charge data prior to billing interface and claims submission. Assist Revenue Cycle personnel with payer and patient questions about charges. Maintain reporting system of audit activities and identifies patterns and trending of results. Function as resource for all hospital departments with charging questions and issues. Routinely review and analysis of inpatient and outpatient records for appropriate charging. Provide educational sessions for revenue producing departments regarding appropriate charging process and procedures. Collaborate cooperatively with the Patient Financial Services staff and other health care professionals in obtaining correct charges and billing protocols. Assist the Health Information Department with RAC requests, coding reviews, and denials. Educates Departments and staff on the analysis and trending of hospital or provider audits and assists provider services with educational efforts. Must be able to communicate effectively verbally and in written format to clinical and non-clinical staff and individuals. Familiar with coding diagnostic and procedural information from the record using ICD-10-CM and CPT/HCPCS classification systems, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary or payer guidelines. Consistently maintain established productivity requirements and maintain a 95% or greater accuracy rate. Attends hospital-wide orientation, in-services, educational meetings, and attend other continuing education functions as necessary to maintain credentials. Exhibit excellent customer relations to patients, visitors, physicians, and co-workers. Show courtesy, compassion, honesty, and respect to others in the adherence to the Hospital's mission, philosophy, and policy for promoting a positive work and customer environment. Adhere to CRH's confidentiality policy for all information related to patients, family and friends, hospital employees, physicians, and clients. Demonstrate a commitment to flexible work scheduling when necessary. Advises and collaborates with Internal Audit, Regulatory Review and Analysis, and outside consultants to analyze, review and assess identified billing, coding, charging and compliance issues. Understands and reviews payer remittance advises, remit/remark code reason codes and how the codes translate into denials. Understands denials prevention, root causes and works effectively to identify trends. Perform other related duties incidental to the work described herein.

 

 

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education: Associates degree in health information management or a related field.

Preferred Education: Bachelors degree in health information management or a related field.

Experience: Coding experience of at least 5+ years in coding position, with coding ability demonstrated via a skills assessment or current certification. Experience with health information systems and computer technology required. Ability to communicate effectively, both verbally and in written format. Must be able to work independently with attention to detail and accuracy.

Certificates, Licenses, Registrations:

Current coding certification