Responsible for maintaining, analyzing, standardizing, and modeling revenue charges; providing reference material and charge compliance education; assisting financial planning and analysis; clearing revenue integrity-related work queues in EPIC and identifying trends related to the root cause of edits.
MAJOR ACCOUNTABILITIES
Reviews analyze and verify the accuracy of CDM, fee schedules, and associated master files. Performs, documents, and communicates annual/interim price adjustments. Assists the Director of Revenue Integrity with driving charge capture and revenue reconciliation at the department level to ensure all charges are being captured. Promotes and implements common statistics and productivity units accumulated via charge master services, common billing codes for similar services, common revenue billing requirements for managed care contracts, and common strategic pricing and mark-up formulas for selected facilities/programs.
Ensures CDM updates occur on a regular basis, synchronize financial systems with CDM maintenance vendor tool monthly, scripts work smoothly, new users are trained, and regular communication with CDM maintenance vendor support with issues and suggestions to continue to enhance the product. Makes clear and concise business decisions on updates to the CDM using an advanced understanding of CPT, HCPCS, ICD10, third party billing requirements and extensive knowledge and experience with Medicare/Medicaid regulations.
Provides assistance, investigation, research, interpretations, education, reference material, documentation, and policies for CDM-related and Compliance issues/questions to internal and external partners. Interfaces with and provides education and training to clinical staff to improve charging process, and provide technical support regarding revenue systems to business customers including, but not limited to, Clinical departments, Information Technology, Administration, Patient Financial Services (PFS), Finance, Accounting, Managed Care Contracting, and Business Partners.
Performs periodic reviews of each CDM to inactivate or zero-out obsolete, inactive, and non-billable charge codes. Perform periodic reviews of each CDM to insure statistical and zero-priced non-billable charge codes are flagged as "No-print" in the master files and noncovered CPT/HCPCS codes are flagged as "non-covered" in the master files. Assist with periodic CPT/HCPCS and associated billing code research and make appropriate changes to the Chargemaster. Creates and store CDM master file spreadsheets/files quarterly for reference. Maintains records of most current charge tickets being used by departments. Coordinates updates to the charge ticket when charges are added or removed from the department Chargemaster.
Supports the ongoing efforts of the Director of Revenue Integrity to maintain charging, coding, billing, and pricing that is compliant with government regulation and the policies of Cottage Health. Provides input and feedback regarding modifications and improvements of CDM-related policies and procedures and reference material related to CDM maintenance, charging protocols, and charge code data accuracy. Supports the finance, operations, and revenue cycle teams through special projects.
Validates and updates chargemaster price and billing elements by receiving feedback from PFS charge audits, managed care contracting, external audits, and CDM reviews. Maximizes reimbursement and minimizes billing rejections by updating chargemaster data elements in conjunction with PFS. Coordinates periodic independent reviews of CDMs for accurate charge code billing elements. Consistently delivers concrete, relevant results. Displays qualities of resiliency and resourcefulness while thinking strategically and practically when problem-solving. In addition to results orientation, displays business knowledge, speed and decisiveness, and project management.
Conducts periodic reviews of outpatient clinical departments to evaluate charge compliance and make necessary adjustments to charging practices using education, charge redesign, or other means appropriate to produce compliant charging and billing practices. Mentors, supports, educates, and trains the IV Outpatient Charge Analyst related to charging practices, creating edits, and non-compliant billing. Conduct supply audits to determine the validity of supply charges from a compliance standpoint, evaluates cost and mark-up to ensure the integrity of the mark-up structure.
Assists with revenue integrity work queues to assist with coding and charge-related issues. Identifies root causes of edits to help eliminate edits that may otherwise be avoided, and provide training and education to clinical teams as appropriate. Ensures charge review work queues are actively managed by clinical staff. Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and adopting and implementing industry best practices.
QUALIFICATIONS
Bachelor's degree, American Association of Healthcare Administrative Management (AAHAM) Certified Revenue Integrity Professional (CRIP) within one year of hire date. Coding certification (CCS, CCS-P, CPC, COC), knowledge of MS Excel. Knowledge of billing requirements related to charges and associated claim forms, knowledge of cost accounting concepts, principles, and computer applications, and experience with electronic medical records and clinical application software. Also requires, 5 years Hospital/Health Care Coding experience Preferred: 3 additional years Hospital/Health Care Billing or Clinical experience
