Revenue Integrity Analyst

Title: Analyst, Revenue Integrity

Department:  Finance, Revenue Cycle Management

Reports To:  Director, Revenue Integrity

Cost Center/Job Code:  10000-50131-002129 

FLSA Status:  Exempt

Position Objective:

The candidate is responsible for overseeing and maintaining specifically assigned system Charge controls, developing enhanced charge reconciliation functions at the department level, CDM maintenance, and governmental updates related to Revenue Integrity and Compliance. Provide all levels of support to Luminis Health facilities to ensure revenue recognition, including issue resolution for assigned areas of responsibility. Responsibilities are to resolve issues and assist others with resolving problems related to Revenue Integrity.  Position communicates to internal and external users all corrections, changes and provides education to the facilities and internal customers. Reviews system charge reports and identifies trends, educational needs, workflow problems, and potential system issues.  Generates monthly reconciliation reports and facilitates daily/weekly calls to review the data with the departments heads, hospital administrators, and CBOs. Ensures that any reconciliation issues are resolved promptly.  The position will require reviewing specific account details to support other employees, CBO staff, or Administration when there are questions regarding the charge reconciliation process. They will analyze revenue cycle systems, including reporting data to maintain acceptable reconciliation performance, compliance, user satisfaction, and help develop greater efficiencies to identify charge enhancement opportunities. This position will determine the need for claims to be adjudicated with no further review, review records, or facilitate an onsite audit at the hospital. Develops and documents hospital claims review and audit policies. Collaborates with Luminis Health facilities to provide clinical policy representation at meetings to ensure that decisions, which affect claim processing, are appropriate and will result in cost-effective, efficient, and accurate claims payment. The analyst will investigate provider aberrant/fraudulent billing practices utilizing paid claim data and review medical records. Provides education to employees and provider offices as needed to understand correct claim coding, use of CPT, ICD9, ICD-10 HCPCS, etc.

Essential Job Duties:

• Pulls weekly performance reports and distributes them to organizational stakeholders. Analyzes the reports and summarizes any significant changes or trending;
• Generates daily reconciliation reports. Distributes the results and facilitates calls between the departments, CBO, and Administration to resolve any issues;
• Manages, coordinates, updates, and implements the Charge Description Masters (CDM);
• Provides assistance and analysis to all levels of clinical management in support of suggested, requested, and mandated changes to the CDM;
• Provides education and in-service training to clinical departments concerning the use of proper CPT-4 Codes or charge codes;
• Performs all other duties as assigned or required, including account research, problem-solving any assigned research requests from the facilities, report writing as needed, etc.;
• Conducts review of the chargemaster and updates as appropriate to enhance revenue for clinical departments;
• Conducts audits of Corporate CDM against all individual department CDM systems;
• Analyzes data within the CDM and assigns CPT/HCPCS and revenue codes to the ChargeMaster;
• Review revenue cycle systems and clinical systems to maintain charge integrity and develop greater efficiencies for charge recognition;
• Responsible for making CDM related decisions that require a higher-level analysis and investigation;
• Identifies billing irregularities on hospital bills and recommends the next level of review, including telephonic discussions with the hospital, referral to the vendor, or onsite audit at the hospital.  Recommends solutions to resolve billing inconsistencies;

Educational/Experience Requirements:

• BS in Finance, Accounting or Healthcare related field preferred

Required Minimum Experience:

• 2+ years experience supporting Revenue Cycle and Clinical systems;

Required License/Certifications:

1. Certification as a Registered Health Information Administrator (RHIA) is preferred
2. Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Outpatient Coder (COC) certification preferred.
3. Healthcare Financial Management Association (HFMA) Certification preferred
   • National Association of Healthcare Revenue Integrity (NAHRI) certification preferred

Knowledge, Skills, Abilities:

• Knowledge of healthcare revenue integrity principles
• Understanding of departmental charge structures
• Ability to perform daily charge reconciliations
• Knowledge of clinical orderable as it relates to charges
• Knowledge of Revenue Integrity technological tools

Working Conditions, Equipment, Physical Demands:

Light work. Exerting up to 20 pounds of force occasionally, up to 10 pounds of force frequently, and a negligible amount of energy constantly to move objects. If the use of arm and 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.

There is reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements.