Job Summary:

The Revenue Integrity Specialist coordinates, evaluates and measures revenue integrity operations; develops systems to manage medical necessity denials; and develops tracking mechanisms to measure loss leaders and improvements by service line, payer and provider.

Reports to:

Patient Access Supervisor Essential Functions:

Document and track all RAC and Payer audit requests including maintaining the RAC and Arthur Databases to ensure that all timelines are met. Manager the submission of records and respond to denials and appeals requests. Share RAC findings with key members of the organization. Coordinate and manage numerous RAC notifications in varying phases of appeal based on feedback. Log, notify, and scan all Government correspondence coming into the facility ensuring that all appropriate parties are informed. Maintains e-requests. Works with departments which impact the hospital's ability to develop and document processes which facilitate clean automated billing of hospital claims. This includes identification of people, process, and technology issues, development of appropriate solutions, participation in roll-out of the process improvement solutions, and ongoing monitoring. Will participate on existing teams and initiate and lead project teams as needed. Works with Scheduling, Registration, Clinical Departments, Health Information Management, and the Business Office to ensure all staff that impact the revenue cycle receive needed education and competency assessment. Assists in the preparation of educational material and provides education as needed. Works directly with clinical operating departments, Managed Care & Reimbursement, Supply Chain and business office personnel to ensure the hospital receives all reimbursement to which it is entitled through appropriate charging and coding of patient claims. Assists with SOX audits, insurance denial appeals and patient charge concerns/complaints as needed. Participates in the development of policies and procedures and ensures compliance within the Revenue Cycle. Participates and collaborates in resolution of the Revenue Cycle issues and refinement of the process to prevent future issues. Keeps informed of current healthcare-revenue cycle trends and regulatory changes. Verifies insurance benefits and obtains precertification/authorization as necessary. Determines and accepts required payments, including co-pays and deductibles, or refers to financial counselors for follow up. Performs medical necessity check, when appropriate (if not already done so in scheduling or pre-registration process). Able to provide coverage to other areas of registration when necessary.

Education/Experience:

High school diploma or equivalent Required. College education or 2 years experience preferred. Minimum Work Experience Two years' hospital revenue cycle experience preferred. Physician billing/reimbursement experience helpful. Demonstrated expertise in patient accounting management and billing systems including their uses, capabilities and limitations. Experience with coding (CPT, diagnosis, revenue and insurance codes, etc.) and a working knowledge of billing regulations, including but not limited to Medicare IP PPS and OPPS, Medicaid and commercial billing guidelines, a must. Strong understanding of Hospital Charging and rate structure.

EEOC Statement:

Starr Regional- Health and Rehab is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.

Qualifications:

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