PFRT Rev Integrity Specialist

UMass Memorial Health•Worcester, MA

10d•$64,085 - $115,336•Onsite

About The Position

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Serves as a Charge Generation Tracker (CGT) and regulatory gatekeeper to ensure compliance with coding and billing guidelines. Reviews all assigned edits within prescribed timeframe and routes to appropriate owner for resolution. Provides regulatory (coding and billing) support to clinical charge capture specialists to address CGT, coding, charge capture and billing questions. Acts as primary resource for providers, clinical and administrative staff for coding questions and research related to revenue enhancement and correct coding.

Requirements

Associate’s degree.
Certification in Professional Coding. (CPC) Certified Professional Coder.
EPIC Credentialed in Ambulatory within 12 months of hire date.
Three to five (3-5) years of work experience related to professional billing and coding.
Knowledge of industry standard practices, including CPT / HCPCS codes and third-party reimbursement policies.
Knowledge of coding and billing requirements based on third party publications, including Blue Shield, Medicare, Medicaid, commercial insurers and HMOs / PPOs.
Strong interpersonal and communication skills required. Ability to speak and present in front of groups required.
Detail oriented, strong analytical skills with the ability to multi task and prioritize required.
A working knowledge of Microsoft Office applications, ability to develop reports and create presentations.

Responsibilities

Serves as a gatekeeper to ensure that regular and annual CGT updates compliant with third party regulatory and coding billing guidelines and reflect clinical practice.
Collaborates with clinical / ancillary departments to facilitate proper use of CGT files as well as synchronization of preference lists and orders in IT applications.
Ensures system wide compliance with federal, state and local regulations with regard to charge codes and related information in the CGT.
Ensures standardized CGT request processes are followed.
Reviews all assigned edits within prescribed timeframe and routes to appropriate owner for resolution.
Provides support and guidance to clinical and RI / Charge Capture staff to resolve outstanding edits.
Monitors daily edits reports and alerts clinical departments of delinquencies.
Provides regulatory (coding and billing) support to clinical charge capture specialists to address CGT, coding, charge capture and billing questions.
Utilizes subject matter knowledge to support proper interpretation and analysis of performance report(s).
Utilizes reporting and data analysis in combination with standard benchmarks and criteria to identify and follow-up on potential revenue integrity issues.
Ensures the CGT structure supports effective capture of all chargeable services based on a thorough knowledge of the regulatory requirements, IT applications and charge capture processes.
Provides subject matter knowledge related to the CGT for clinical departments, revenue cycle team, finance, compliance and administrative staff.
Provides accurate feedback and documentation to support educational needs.
Develops and conducts educational courses and seminars focusing on professional documentation, coding and billing for physicians, clinicians, administrative staff and Professional Billing Central Billing Office (PBCBO) staff.
Develops training programs and supporting materials relative to physician coding and billing guidelines and protocols to ensure that specific areas of need are addressed and that all materials comply with applicable rules and regulations.
Participates in PBCBO staff training on coding and billing guidelines.
Monitors CMS and applicable third party coding and billing publications, and abstracts key information relative to established coding and billing policies and procedures for distribution to UMMMG stakeholders (clinical, administrative, compliance, PFS, finance).
Researches third party coding and billing guidelines and ensures timely and accurate compliance with federal, state, local payer requirements as well as UMMMG contracts specific to charging, coding, bundling and unbundling, modifier reporting requirements.
Leads annual review process by providing updates regarding CPT, CMS regulatory updates, professional society publications (e.g., ASA) for clinical, administrative, compliance, revenue cycle, and finance.
Performs quality audits and reviews of focused patient accounts to identify improvement opportunities in clinical documentation, charge capture and coding.
Provides audit feedback to key clinical and revenue cycle stakeholders for continuous improvement.
Monitors downtime forms for each billing area.
Collaborates with clinical charge capture analyst to ensure that downtime procedure is maintained.
Complies with established departmental policies, procedures and objectives.
Attends variety of meetings, conferences, seminars as required or directed.
Demonstrates use of Quality Improvement in daily operations.
Complies with all health and safety regulations and requirements.
Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.
Maintains, regular, reliable, and predictable attendance.
Performs other similar and related duties as required or directed.