Job Description

POSITION SUMMARY:

This position assists in resolving billing edits that are holding patient claims from billing by reviewing medical records and other applicable documentation. Maintains the integrity of facility STAR Charge Description Master (CDM), HSM and all Revenue Integrity Processes. Maintains the integrity of all Ancillary Department systems related to billing and revenue. Researches and handles all processes regarding the charge master not limited to adding new charges, modifying and inactivating charges from the CDM. Ensures all applicable coding and billing guidelines are met. Position will work with Ancillary Department staff to research alternative processes regards to charge related improvements and billing compliance issues. Position will coordinate all retrospective, concurrent, patient complaint and external billing audits. Provide monthly audit results. Develops and coordinates educational in-services to the Business Office staff and Ancillary staff related to charging and billing issues. Reviews denial trends for documentation or charging issue opportunities. Reviews high charge stays/procedures for charging accuracy. Ensures Issues logs, Unbilled reports are addressed properly and timely. Stays abreast of governmental and non-governmental payors to ensure facility charging meet compliance and clinical documentation processes in place will support charges. Performs various QA reviews to ensure timely and appropriate charging, documentation to support charging, appropriate coding at charge level and all UB04 fields. The Revenue Integrity Nurse Auditor position interprets policies and procedures, recommends changes as appropriate, and provides relevant feedback to the departmental leadership.

KEY RESPONSIBILITIES:

• Analyze and resolve patient claims being held by billing edits that would be the responsibility of RI on the Failed claims, Failed bill, Issues, Rebill, HIM and Unbilled logs, Correct Coding Initiative, Self-Administered and other claims requiring clinical and hospital business office expertise.
• Interacts with ancillary departments to obtain additional information needed to properly bill account based on documentation in the medical record.
• Identifies charging, coding, or clinical documentation issues and works with ancillary departments to resolve issues and notify appropriate leadership.
• Reviews all Trailblazers, CMS, OIG, correspondence and adheres to all guidelines.
• Performs assigned audits by researching documentation, analyzing information, and makes recommendations to improve flow of claim and enters all corrections into the systems.
• Stays abreast of regulatory requirements and company compliance policies, payer requirements, significant changes and developments to ensure quality review measurements are in place at the facility.
• Performs daily QA on all surgical accounts to ensure timely and accurate charging and appropriate clinical documentation to support charging.
• Identifies and works with management to implement process improvements to lower costs and improve services to facility customers.
• Adheres to all compliance guidelines and maintains strictest confidentiality.
• Supportive of the compliance program set forth by Steward Health Care as demonstrated by:
o Upholding the Code of Conduct and Corporate Compliance.
o Adhering to and helping to enforce all compliance policies relevant to his/her area.
o Assuring timely compliance education as requested by the Regional Compliance and Safety Officer.
o Setting an example to all staff in their daily activities.
• Perform other duties as assigned by Manager and/or Director.

REQUIRED KNOWLEDGE & SKILLS:

• Excellent communication skills both verbal and written.
• Good interpersonal skills.
• Able to establish good customer relationships with trust and respect.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

Education:
• BSN preferred.

Experience (Type & Length):
• 3-5 years' related experience required.

Certification/Licensure:
• LPN; RN preferred.

Software/Hardware:
• Navigation and edit resolution through various Web based systems, Ability to use email, Excel, Word.

Application Instructions

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