Job Summary

This position reports to the Executive Director of Hospital Revenue Cycle Operations and is responsible for implementing, developing, coordinating, and leading the Revenue Integrity department. Ensures the overall consistency and integration of integrity activities throughout the organization. Develop the alignment of the revenue integrity program with applicable policies and procedures and all applicable laws, standards, and regulations. Create and maintain staff job descriptions in accordance with best practices and according to NGHS' needs. Works alongside the charge description master (CDM) department to review alignment with finance and reimbursement policies and guidelines. Drives communication of CDM changes to impacted clinical departments. Reviews, revises, and develops policies for adoption via institutional processes, as appropriate, to compliment and reinforce the revenue integrity department. Works closely with executive leadership to ensure that the revenue integrity department meets applicable financial, operational, and legal requirements. Provides periodic reports to executive leadership regarding the nature, progress, and status of the revenue integrity program, any corrective action being taken, and any recommended changes. 

Job Specific and Unique Knowledge, Skills and Abilities

• Must have the ability to work under pressure with time constraints and have the following skills and aptitudes

• Strong knowledge base in complete and accurate clinical documentation in all healthcare settings and for all healthcare disciplines. 

• Strong knowledge base and experience in coding and billing practices.

• Knowledge of the conventions, rules, guidelines for multiple classification systems. Knowledge of multiple reimbursement systems.  

• Knowledge of multiple regulations, standards, policies, and requirements pertaining to clinical documentation, coding, and billing.

• Knowledge of multiple third-party payer requirements.

• Ability to accurately interpret and implement regulatory standards and interpret legal requirements. 

• Ability to establish rapport with physicians and other healthcare practitioners

• Strong managerial, leadership, and interpersonal skills. Strong analytical and problem-solving skills

• Strong knowledge base in compliance requirements. Experience in clinical documentation and coding, including strong familiarity with coding of CTP codes an HCPCS.

• Firm understanding of the Medicare IPPS, OPPS and ASC payment systems.

• Expert level Excel and PowerPoint skills

• Strong presentation skills, written and verbal, in small groups and large, to staff, leadership and clinical teams.

Essential Tasks and Responsibilities

• Develops, coordinates, implements, and oversees the revenue integrity program and team.

• Acts and leads in a manner that is reflective of the philosophy, vision, and values of NGHS. Integrates these values throughout all initiatives and efforts.

• Uses a proactive leadership style to model and promote a culture of trust and communication. Seeks suggestions and input from staff and colleagues. Promotes an active participation of all staff in decisions that affect them.

• Holds all staff members accountable for following and adhering to all applicable rules, regulations, laws, and guidelines.

• Monitors revenue departments’ adherence to charge reconciliation processes and metrics measured by key performance indicators.

• Supports clinical departments related to new revenue initiatives, such as being the subject matter expert in the development of new CDMs to support the new clinical service offering.

• Coordinates with CDM department to ensure necessary changes that affect charge identification, capture, reconciliation and claim progressing are flowing effectively.

• Monitors and assesses integrity risks and ensures that the revenue integrity program is responsive to those risks.

• Provides periodic reports to the Executive Director regarding the nature, progress, and status of the revenue integrity program, any corrective action being taken, and any recommended changes.

• Ensures staff members are knowledgeable about revenue assurance needs and reimbursement issues identified through audits, reviews, and aggregate data analysis.

• Reviews changes in CPT, HCPCS, and revenue codes for accuracy, compliance with applicable billing guidelines, and optimization of reimbursement.

• Develops tools to track and identify potential areas of lost revenue.

• Develops tools to track and identify potential areas of compliance risk.

• Monitors national, state, and local information to keep current with applicable regulatory and legislative changes and tailors the revenue integrity department accordingly.

• Oversees and coordinates all formal communication with department team and other NGHS staff.

• Works closely with other Department managers to ensure an efficient and effective flow of information leading up to and following the revenue integrity functions.

• Encourages staff to attend educational opportunities relevant to their position and supports their attendance.

• Promotes a service-oriented culture within the organization and assures satisfaction with the quality and amount of support provided for departmental functions, initiative, and projects.

• Intervenes in an accurate and timely manner when pertinent information is required allowing efficient workflow process

• Researches and recommends various technology tools available to support revenue integrity initiatives.

• Serves as the 1st contact for revenue integrity related issues.

• Serves as the primary support for all revenue integrity related system issues and communicates with ITS to ensure resolution.

• Ensures the appropriate dissemination and communication of all regulation, policy, and guideline changes.

• Participates in the development of goals and objectives for the Department, related to revenue integrity, as well as short-term and long-range planning.

• Participates in preparing Department budget specific to revenue integrity and manage area within budgeted guidelines.

• Mentors staff daily and follows progressive correction policy where indicated.

• Works with Executive Director to resolve discrepancies or staffing issues and addresses noncompliance to policies and/or procedures in a timely manner. Councils staff and administers corrective action as needed.

• Conducts staff performance evaluations. Seeks input from Executive Director, if needed.

• Utilizes time management skills to ensure completion of daily processes.

• Ensures thorough and appropriate documentation for all assigned staff is being maintained

• Maintains professional development and growth through professional affiliations, seminars, and workshops to keep abreast of trends in Revenue Integrity.

• Responsible for operation of the department and attends meetings throughout the organization as assigned. Completes all employee reports and records according to established time frames: performance reviews, corrective actions and timekeeping. Serves as the key point person and/or assist, as needed, with Revenue Integrity related complaints received by other departments. Responsible for resolving complaints and following up with all parties involved.

Minimum Job Qualifications

• Educational Requirements: Bachelor’s degree in Business, Healthcare, Finance, or Fraud/Risk Management

• Minimum Experience: 10 years of specified experience which includes at least five years of Revenue Integrity leadership experience at the manager level, to include management of people, projects, programs

Preferred Job Qualifications

• Preferred Licensure or other certifications: CPC, CCA, CCS, RHIA, RN, CPAR

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About Northeast Georgia Health System

Northeast Georgia Health System (NGHS) is a not-for-profit community health system anchored by five NGMC hospital campuses and a Level I Trauma Center, all dedicated to our mission to improve the health of our community. We believe that your next role is more than just a job; it’s a major life decision. NGHS fosters a working culture for more than 1,400 medical staff members representing 60+ specialties that prioritizes professional development, career advancement and access to leading technology. Discover how NGHS can support the life you choose to live.

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