REVENUE INTEGRITY SPEC

Covenant Health•Knoxville, TN

2d•Onsite

About The Position

Performs complex level professional internal analysis related to root cause and resolution of denials for corrective action. Work involves research and analysis of revenue cycle projects for Covenant Health entities as they relate to charging, coding, documentation and billing. Maintains all organizational and professional ethical standards. Works under supervision but with significant latitude for initiative and independent judgment.

Requirements

Associates or Bachelor’s degree required in one of the following areas: HIM, Coding, Finance, Business, or Healthcare.
Three (3) years’ experience in health care.
Good working knowledge of healthcare billing, Medicare/Medicaid billing guidelines, and other Third Party Payor rules and regulations.
Experience in problem solving and analytical reviews.
Must be knowledgeable in use of PC's, Windows, Excel and Word Processing.
Must have good public relations skills.

Nice To Haves

State of Tennessee certification in at least one (1) of the approved certifications (RHIT/RHIA, CCS, CPC, or CPMA).

Responsibilities

Reviews ADR log, Denial Management System reports and payor websites to identify denials and other related issues and proactively address gaps in performance.
Reviews information from third party payers relative to claims, charging, coding, and billing in order to ensure compliance with payor rules and claim billing rules.
Performs research and analysis of denials related to charges, CPT coding, modifiers and billing processes to recover denied reimbursement as appropriate.
Validates that all steps in the appeals process are followed per contractual and regulatory guidelines.
Provides education to auditors, nurse and coders in department relative to denials and appeals processes based on final review of denial. Escalates concerns to leadership team as necessary for action.
Prepares and packages appeals submissions for ALJ, Independent Review and Binding Arbitration.
Prepares and maintains all payor issue lists related to denials as necessary for presentation to third party payors with coordination of leadership team.
Researches and validates complaints submitted by Revenue Integrity Auditors related to payor process and handling of appeals with escalation to leadership team.
Coordinates payor meetings relative to denial and process complaints for resolution with payors in collaboration with supervisor.
Provides on-going feedback to colleagues related to research performed, analysis of denial trends and appeal process gaps.
Coordinates with appropriate parties the complete/ partial payment or repayment of the claims as findings are identified that are either over-payments or underpayments.
Documents all denial activities in a designated location; reports statistics and identified problems monthly or more urgently if deemed necessary.
Develops and ensures compliance with workflows necessary to streamline processes for third party vendors and payors (e.g., Xsolis, Humana, and Advent) in denials management. As necessary, escalates concerns to leadership team.
Validates all invoices for third party vendors and prepares them for processing. Works directly with vendors if unable to reconcile. Escalates to leadership team as applicable.
Assists with special projects and performs other duties as needed and requested by the Vice President of Patient Account Services, Officer and/or Corporate Manager of Revenue Integrity.
Supports, models and adheres to the desired behaviors of the KBOS Constitution for quality which are; celebrate and reward successes, seek out better ways to do our job, set improvement goals and standards striving to meet or exceed them, participate in forming and being part of work teams when necessary and do not say "It's not my job.”
Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
Performs other duties as assigned.
Works in conjunction with health information management, patient accounting, Revenue Integrity, information systems and other personnel on root cause and analysis of denials to assist with implementation of solutions to maintain a proper revenue stance.
Works closely with Financial Analysts to identify process improvement activities and audit opportunities based on denial trends.
Works closely with co-workers to identify process improvement activities and audit opportunities.
Coordinates and facilitates problem resolution sessions where multiple departments and/or service areas are involved as deemed appropriate by manager.
Works with physician advisors and attorney in coordinating ALJ hearings, Independent Review, and Binding Arbitration presentations and hearings.
Supports, models and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for service which are; take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect and use customer feedback/data to improve processes and service and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, keep commitments.
Maintains lines of communications with departments in an ongoing effort to improve the overall quality of customer service.
Promotes good public relations for the department and the Finance Division.
Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability and professionalism.
Supports, models and adheres to the desired behaviors of the KBOS Constitution for caring which are; build a trusting environment by listening with an open mind and valuing different opinions; asking questions for understanding and allowing others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work and respect differences by listening with an open mind.
Maintains professional growth and development through continuing education, seminars, and applicable professional affiliations to keep informed of industry trends.
Recognizes situations which necessitate supervision and guidance and seeks to obtain appropriate resources.
Coordinates with staff to ensure necessary materials, equipment and/or supplies are maintained utilizing all avenues of resource management in ordering supplies for departmental needs.
Utilizes resources available appropriately, i.e. use of Covenant Health equipment and/or supplies.
Does not promote or participate in solicitation during working hours within the department.
Supports, models and adheres to the desired behaviors of the KBOS Constitution for using the community’s resources wisely which are; be aware of cost and quality when making spending decisions, demonstrate a personal commitment to reduce waste, consider the impact on other departments and facilities within Covenant Health when making decisions or taking action and ensure that meetings lead to solutions.