Overview
Our Billing & Revenue Integrity program will be implemented and can assist with both operational efficiency and compliance. Our program supported by the right combination of existing personnel will help protect the integrity of the facility revenue through organizational awareness and education by monitoring revenue through thorough analysis as well as coordinate with cross-functional teams to resolve charge & billing integrity issues. Objectives of our program include identifying and correcting processes that lead to revenue leakage and assurance that services and items are documented, reported and paid according to contract terms. Additional info related to roles and responsibilities is included below. The benefits of an effective Billing & Revenue Integrity Program include the following:
- Maximizes revenue capture & Ensures billing compliance with state, federal & payor specific requirements
- Creates operational synergies across the enterprise
- Improve first pass payment rate & clean claim rate
- Ability to support refinement of upfront processes and technical solutions with Patient Acctg Systems, Billing editors and other key tools leveraged throughout the enterprise
- Identify and trend disputes & denials
- Identify charging issues; perform root cause analysis and provide effective resolution
- Provide education to staff on appropriate billing & charging practices
- Educate departments/staff on annual CPT changes (collaborate with CDM coordinator)
General Summary of Duties
The Billing Integrity Manager for managing Claim audit and adjustment functions and driving projects to prevent repetitive errors. Surgery Partners is committed to building a team of people, effective process improvement strategies to help eliminate waste.
The Billing Integrity Manager is responsible for relationship management between our Billing Editor platforms, other key teams that will assist with the up front billing edits to improve our first pass payment rate, performing root cause analysis, and proposing improvement projects to prevent repetitive errors. This position will ensure overall quality of claim payment.
Responsibilities include:
- Experience in analyzing, trending and categorizing payer denials
- Serves as a subject matter expert and in a consultative role to various levels of customers including patient accounting systems and clearinghouse
- Understanding of 835 CARC, Remark and Reasons codes
- Knowledge of Payer Portals and IVRs
- Ability to manage and prioritize high volume analysis request
- Conducts claim audit reviews across multiple claim types, patient accounting systems and billing editors. We must determine if claims are appropriately paid in accordance with benefits, contracts and edits, includes review of specific coding and billing guidelines
- Documents findings within audit tracking system in a thorough and objective manner and with high accuracy
- Validate rejections, payments, etc….
- Reprocess claims according to National Billing Standard guidelines and established payment policy.
- Coordinates with clinical team for clinical validations audits
- Work to identify, document, and propose solutions for areas of improvement
- Perform other duties as assigned to support payment integrity functions
Attributes to success:
- Curiosity and willingness to ask questions
- A deep desire to improve and make a change in the healthcare experience
- Preference towards collaboration and preventing silos
- You will have some travel to key locations where needed
- Must love to dissect data and create a story within the root cause analysis performed
- Ability to work in a fast-paced start-up environment
Desired skills and experience:
- Experience in a variety of Patient Accounting systems/EMRs
- Experience with Claims Clearinghouse technologies
- 1-2 years experience in an auditor role with responsibilities across multiple Billing Integrity disciplines
- 1-2 years experience processing claims across multiple claim types
- Working knowledge of Medicare policies and claim and insurance terminology.
- Experience contributing to improvement of audit query concepts
- Excellent ability to build and maintain positive relationships with business and 3rd party partners
- Experience with performing root cause analysis of claim rejections and payment variances
- Strong written, verbal, and interpersonal communication skills required
- 1-2 years experience contributing to development of Standard Operating Procedures a plus
- CPC (Certified professional coder) also a plus