Revenue Integrity Senior Analyst - HMFP
- Woburn, MA
- Permanent
- Full-time
- Monitor departments' adherence to professional charge reconciliation, work-queue, and professional coding quality expectations and support departments with education, process improvement, and follow-up.
- Conduct periodic departmental reviews of professional charge reconciliation processes to ensure adherence to policies and confirm all professional charges are captured and reported accurately
- Review and document changes within the charge description master (CDM) and fee schedule(s) and ensure these changes are implemented within appropriate systems. Route for approval according to HMFP's established policies and procedures.
- Lead annual, quarterly, and regular CDM and fee schedule maintenance activities.
- Review changes in CPT, HCPCS, and wRVUs for accuracy, compliance with applicable coding and billing guidelines, and optimization of reimbursement.
- Support departments with analyzing services for coverage and reimbursement.
- Work with HMFP departments to identify revenue management opportunities, staying current with government and commercial payer's billing and coding requirements.
- Develop, deliver, and revise revenue integrity and coding education and training programs in coordination with the Director and HMFP Compliance Department.
- Monitor, investigate, and report revenue integrity and coding quality concerns to appropriate stakeholders and provide any necessary follow-up.
- Monitor national, state, and local information to keep current with applicable regulatory and legislative changes and tailor the revenue integrity program accordingly.
- Monitor coder quality audit results and coder productivity. Support departments by establishing audit processes, education and training, process improvement, and follow-up.
- Lead assigned revenue integrity and coding projects, committees, and meetings.
- Develop and execute tools and processes to identify potential areas of delayed or lost revenue. Collaborate with departments on process improvement and necessary follow-up.
- Build strong relationships and facilitate effective communication between key stakeholders. Collaborate with others to develop and implement action plans to resolve revenue integrity and coding issues.
- Prepare oral and written reports and presentations summarizing reviews, findings, recommendations for improvement, and actions taken for the Director and other stakeholders.
- Bachelor's degree required.
- Certification: Certified Professional Coder (CPC) required.
- 5 or more years physician/professional revenue operations experience with a focus in one or more of the following areas: coding, revenue integrity, charge reconciliation, charge compliance, charge auditing, CDM management.
- EPIC PB experience preferred.
- Extensive knowledge of:
o code sets to include Common Procedural Terminology (CPT), Health Care Procedural Coding System (HCPCS), and International Classification of Diseases (ICD-10)
o reimbursement theories to include RBRVUS, MPFS, and managed care
o NCCI edits and Medicare LCD/NCDs
o health care documentation, coding and billing requirements as well as federal and state health care regulatory requirements
o health care compliance
o medical terminology, anatomy and physiology along with clinical department activities.
- Abilities:
o Excellent communication, presentation, organizational, analytical and problem-solving skills. Must communicate effectively with physicians, leadership, and other billing personnel.
o Must approach problem solving challenges independently, have strong attention to detail and enjoy working in a fast paced, collaborative team based environment.
o Advanced skills with Microsoft Office, including Outlook, Word, Excel, PowerPoint, Power BI and other web-based applications. Ability to produce complex documents.
o Strong analytical ability. Skills to collect, organize and analyze data, produce actionable reports, and recommend improvements and solutions.Social/Environmental Requirements
- Work requires periods of close attention to work without interruption. Concentrated effort of up to 4 hours without break may be required.
- Work requires constant response to changing circumstances and using new information to adjust approach and to quickly respond to new needs.
- No substantial exposure to adverse environmental conditions.
- Health Care Status: NHCW: No patient contact. Health Care Worker Status may vary by department
- Close work (paperwork, visual examination), Color vision/perception, Visual monotony, Visual clarity> 20 feet, Visual clarity feet, Conversation, Telephone.
- Sedentary work: Exerting up to ten pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally.
- This job requires constant sitting, Keyboard use. There may be occasional walking, standing.