Responsible for performing in-depth analysis of patient clinical and billing data to identify documentation, coding and denial prevention. Develops and implements action plans for denial prevention based on root cause analysis findings. Promotes revenue cycle operational efficiency, data integrity and compliance with billing and regulatory guidelines. Responsible for working complex denial coordination with intra-team members to identify root cause. Performs audits and collaborates with intra and inter-departmental teams on compliance, education, accuracy in charge capture and improvement in the revenue cycle processes as identified through revenue cycle audits and root cause analysis. Works closely with clinical areas to effectively document services performed and understand relationship of documentation, medical necessity, coding and charging for all services provided. Completes assigned reports timely and accurately. May be required to travel between locations within the Region.
1. Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions
2. Collaborates with intra-departmental team on denial investigations and root cause analysis, which includes identifying opportunities for denial prevention along the revenue cycle. Performs analysis of data and reporting of trends, performance metrics, process improvements and impact to revenue.
3. Performs other revenue optimization activities as appropriate, which includes providing education, process improvement, ongoing assessment and resolution of root cause issues. May assist centralized charge control team when necessary.
4. Conducts departmental audits to ensure proper documentation and compliance with state and federal guidelines relating to the charge capture and billing of services. Prepares and submits audit findings, makes recommendations, and works closely with revenue integrity leadership and inter-departmental leaders to implement solutions.
5. Collaborates with clinical departments, Patient Business Service (PBS) center, Payer Strategies, Compliance and other revenue cycle departments on denial coordination, denial prevention and pre-bill edit prevention.
6. Works closely with Revenue Liaison and/or Physician operational leaders, on system implementations, enhancements and new service line requests to ensure revenue cycle integrity and compliance.
7. Works with ancillary teams and providers to develop processes to prevent future denials.
8. Works in conjunction with leadership to track potential risk accounts and reviews with Finance to ensure there are no impacts to current reserves in the Bad Debt Charity Operational write-offs (BCO) model.
9. Attends meetings with payer representative and/or vendors to address outstanding issues and/or stay informed of new regulations or guidelines. Attends monthly denial management meetings at individual ministries.
10. Coordinates denials and appeals and/or reconsideration requests on clinical, coding and technical denials with PBS center, which may include outpatient RAC denials and appeals. Maintains denial and/or appeals logs and assessments in accordance with associated guidelines.
11. Maintains an understanding of regulatory and payer changes to assure correct charging and billing requirements are met.
12. Maintains working knowledge of coding and billing regulations for all payors. Keeps current on regulatory updates, local payer policies and procedures to ensure charge accuracy, compliance and optimization.
13. Other duties as assigned.
14. Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior
Must possess a demonstrated knowledge of clinical processes, charge master maintenance, clinical coding (CPT, ICD-10, revenue codes and modifiers), charging processes and audits, and clinical billing as normally obtained through a Bachelor's degree in Healthcare or Business Administration, Finance, Accounting, Nursing, or a related field, or an equivalent combination of years of education and experience.
Five (5) or more years of experience in billing, charge documentation, charge audit or charge capture activities, or other functions related to revenue cycle activities.
Proficiency with MS Excel, Access, Business Objects highly desired, and strong level of competency with Word and PowerPoint.
Working knowledge of third party payer rules and requirements, computer operations and electronic interfaces related to charge documentation, capture and billing is required. Licensure / Certification: RHIA, RHIT, CCS, CPC/COC or other coding credentials strongly preferred. CDC (Healthcare Compliance Certification) preferred.
Must possess a demonstrated knowledge of clinical processes; charge master maintenance, clinical coding (CPT, HCPCS, ICD-9/10, revenue codes and modifiers), charging processes and audits, and clinical billing.
Knowledge of Ambulatory Payment Classification (APC), and Outpatient Prospective Payment System (OPPS) reimbursement structures and prebill edits including Outpatient Coding Edits (OCE)/Correct Coding Initiative (CCI) edits and Discharged Note Final Billed (DNFB).
Must be able to work in an environment that may be stressful with a variety of individuals having diverse personalities and work styles.
Exceptional organizational skills and ability to prioritize and manage multiple functions and responsibilities simultaneously.
Experience with post payment audits and with coding, clinical and technical denials is required.
Excellent interpersonal, verbal and written communication and organizational abilities. Accuracy, strong analytical skills, attentiveness to detail and time management skills are required.
Must be comfortable operating in a collaborative, shared leadership environment.
Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
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