Job Summary : The on-site Sr. Revenue Integrity Analyst reviews and revises accounts to achieve revenue enhancement and compliance. This position updates and reviews accounts to ensure accurate and complete charge capture and accurate, timely billing. The incumbent establishes and maintains a library of rule, regulations, policies and procedures of all governmental and commercial payors. Responsibilities: Assist various departments in ensuring all denials are captured appealed in a timely manner. Coordinating appeal discussions with clinical third party payors. Develop, Implement and coordinate billing practices between hospital and physician groups to ensure uniform coding and documentation. Recommend sound financial best practices that are able to withstand audits. Foster continuous improvement of revenue cycle processes through education with various departments. Identify pre-bill and post-bill claim edits involving any type of clinical or coding review or required modifier based on services rendered. Analyze and maintain WMCHealth Network Hospitals CDMs to maximize revenue. Performs periodic review of codes and works with patient billing regarding bundling and unbundling services as delineated in CMS and CCI edits. Coordinates and serves as liaison with CDM software companies to evaluate and validate CPT and revenue codes and related coverage issues. Engage with various departments to identify opportunities during EMR implementation and provided feedback and recommendations. Serves as the finance liaison with ancillary departments regarding CDM service and procedure changes and educates departments regarding the impact of CDM regulatory changes. Researches technical guidance in UB-92 Editor, CPT/HCPCs Guide, CMS website, Medicare Manuals, etc. to resolve billing issues and promote regulatory compliance. Maintains and provides information on status of audits and issues presented. Participates in quantifying audit outcomes, including revenue realized Researches and communicates appropriate treatment of charges to clinical managers, CDM Specialist (coordinator), other customers. Participates in required regulatory change implementations and ongoing monitoring related to compliant charge capture. Performs other duties as assigned. Qualifications/Requirements: Experience: Minimum 8 plus years clinical experience in a hospital setting, preferably cardiology, radiology, surgery or utilization review , required. Previous revenue integrity experience, Excel and Electronic Medical Records experience preferred. Education : Graduate of an accredited program (RN,MD,PA), degree in healthcare preferred. Bachelors degree or equivalent work experience (8 plus years) required. Licenses / Certifications: Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H), preferred. Other: Familiarity with medical record documentation standards and practices, health care insurance billing issues, and federal and state billing compliance issues for hospitals; knowledge of CPT-4 codes and ICD-9-CM codes is preferred. Special Requirements: Requires travel to other WMCHealth Facilities.
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