Revenue Integrity Analyst - Concord, Ca (On-Site)

Summary: Revenue Integrity Analyst

The Revenue Integrity Analystworks directly with the Revenue Cycle billing team and proactively performs charge capture analysis and resolves EPIC Pre-Bill suspended charge/revenue loss billing edits. This position will develop and maintain the Non-System charge description master (CDM) and audit Revenue Cycle Charge Master maintenance tasks daily to ensure that every service that is received based on clinical documentation is captured, billed timely, and reimbursed. Will perform Proposition 56 Supplemental Rate payment reconciliation and collections. Responsible for the implementation and facilitation of ongoing compliance auditing, monitoring, reporting, and education activities for the revenue cycle. This includes the development and implementation of work flows to support the integrity of PPNorCal revenue cycle.

Essential Functions:

Charge Master

• Research billing and coding regulations to ensure organizational compliance.
• Communicate and submit the necessary documentation and technical data to BOI that is required to implement the necessary changes that impacted policy, financial, charge capture, billing, and coding operations.
• Perform daily maintenance and quarterly audits of the Charge Master to ensure up to date coding and encounter pricing is maintained for billing accuracy
• Liaison with Revenue Cycle, IT, and clinical departments to review the charge master.
• Responsible for the submission and follow up of new service codes and deactivation of outdated service codes and pricing to ensure state, federal, and payer billing compliance.
• Work with Purchasing to ensure that the correct annual and quarterly 340B pricing is maintained
• Maintain current knowledge of Charge Description Master (CDM), Charge Preference List (CPL), and Flowsheet Charging to provide Revenue Cycle support.

Pre-Bill Charge Capture and Reconciliation:

• Monitor the EPIC Revenue Integrity Dashboards.
• Review Health Center appointments vs. encounters reports daily.
• Follow up with Health Center staff to ensure all services are entered into the patient accounting system.
• Work with the Health Centers if system downtime and outages are encountered to ensure that clinical documentation and charges are entered timely for billing.
• Audit charges being captured by clinical departments for accuracy and completeness. Ensure that charges are crossing to the bill as intended for RCM Vendor submissions.
• Troubleshoot charge posting issues. Identify charging opportunities. Manage assigned EPIC work queues.
• Responsible for reviewing and resolving all Pre-Bill suspended charge edits daily to ensure timely system claims data info crossover to the RCM Billing Vendor for Submission to the payer.

Post Visit Revenue Loss Mitigation:

• Perform Proposition 56 Supplemental Rate payment reconciliation and collections activities to include:
  1. Performing calculations of amounts owed to PPNorCal.
  2. Claim level reconciliation of amounts owed to actual payments received.
  3. Communication with payers regarding Prop 56 claim data amounts outstanding.
  4. Ongoing reporting to Finance management regarding collection status
• Audit post visit Charge Coding and clinical data to ensure that the appropriate billing service codes are consistently appended prior to submission to the billing vendor to ensure OIG, state, federal, and payer compliance
• Identify charge capture opportunities (missed billing, over charging, under charging) or compliance issues in revenue producing departments and assist with the interdepartmental implementation of process improvements.
• Review changes in pricing, CPTs, HCPCs, rev codes, etc. for accuracy and compliance with all applicable charging and billing guidelines. Ensure teams stay informed of payor and/or regulatory updates and create action plans to accommodate changes as needed.
• Create and maintain an effective undercharging monitoring and response program. Research and propose fee schedule optimization opportunities to mitigate reimbursement losses.
• Perform monitoring and follow-up to ensure timely repayment is made for all identified overpayments received from government agencies, health plans, and patients.
• Analyze, track data, and create reports to assist in the analysis of compliance issues and claims payment patterns.
• Analyze internal credit balance, automated system and manual vendor contractual adjustment data methodologies daily to assist with identifying and resolving patient accounting inaccuracies before the month end close.
• Actively participate in team development, achieving dashboards, and in accomplishing departmental goals and objectives.
• Maintain up to date and current knowledge of charge capture workflows and proactively maintain and increase knowledge of professional coding and Revenue Integrity compliance through on- going, self-started professional development.

Other Duties and Responsibilities:

• Ensure compliance with existing rules, new rules, regulations and revisions, as set forth by the Center for Medicare and Medicaid Services (CMS) and California Department of Health Care Services (CA DHCS), as well as other federal and state laws and regulations that govern matters related to revenue cycle.
• On a monthly basis, review all changes in industry practices and regulatory environment related to PPNorCal revenue cycle. Report on those changes and implications, monthly. Monitor, analyze, interpret, and communicate regulatory changes related to coding, billing, and collections. Oversee efforts to respond to new or changing regulations, including but not limited to, communicating regulations to affected departments, and developing/providing education regarding regulatory requirements.
• Identify opportunities (e.g., reimbursable items not being charged, etc.) for charge capture and reimbursement improvement using contract and denials management tools/techniques, random reviews (including payment accuracy reviews), review of medical records, and claims data.
• Keep abreast of payer and billing, collection, and general coding requirements; apply knowledge to review that charges are accurate, billed correctly, and supportable according to payor requirements. Research and resolve utilization of CPT and HCPCS codes, revenue codes, ICD-10-CM diagnosis codes and other issues as needed to support charging and billing requirements.
• Report productivity metrics of Revenue Cycle staff to ensure that high productivity and proficiency standards are met. Compile monthly reports from EPIC, Business Objects, TriZetto, and other applications to monitor key performance indicators.
• Actively participate in the advancement of PPNorCal Diversity, Equity, and Inclusion commitment.
• Other duties and Special Projects as assigned.

QUALIFICATIONS:

EDUCATION and/or EXPERIENCE

• Associate degree (A. A.) or equivalent in Business, Finance, Healthcare Admin. Or related field preferred or equivalent combination of education and work related experience in a billing and finance department.
• Certifications in professional services Coding (required) & auditing (preferred).
• Two (2) years of experience with revenue cycle operations. Three (3) years of coding and/or audit experience.
• Thorough understanding of CMS Medicare and Medicaid billing regulations, especially California Department of Health Services (DHCS) Medi-Cal and Managed Care Medi-Cal billing regulations.
• Excellent knowledge of ICD10, CPT/HCPCS and revenue codes, CMS billing regulations and healthcare reimbursement. Must be comfortable developing and presenting revenue cycle compliance education and training.
• In-depth knowledge of private and governmental insurance eligibility and verification, charge capture, CPT maintenance, coding, billing, and collections, payment posting and self-pay.
• Strong knowledge of clinical practice and revenue cycle management including third-party reimbursement guidelines and procedures.

LANGUAGE SKILLS

Ability to read, write and comprehend simple instructions, short correspondence, and memos. Ability to effectively present information in one-on-one and small group situations to customers, patients, and other employees of the organization.

MATHEMATICAL SKILLS

Strong mathematical skills required. Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY

Strong ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

COMPUTER SKILLS

Advanced knowledge of Microsoft Office Suite Outlook, Word and Excel. Knowledge of Electronic Health Records/Electronic Practice Management systems, EPIC experienced strongly preferred.

PROTECTED HEALTH INFORMATION (PHI) ACCESS REQUIREMENT

As required for patient billing requirements.

CERTIFICATES, LICENSES, REGISTRATIONS

Certifications in professional services Coding (required) and auditing (preferred).

Pay Range: Planned Parenthood Northern California (PPNorCal) supports California’s new law (SB 1162) enhancing pay transparency. This new law requires employers with 15 or more employees to include a pay range in job postings. The pay range reflects the compensation that a new employee can expect to receive if offered employment. Employees with more experience, education, and other qualifying factors may be compensated at a higher rate of pay. The pay range for this position is: $75,000.00-$82,500.00 Annualized salary.

Planned Parenthood Northern California is an equal opportunity employer and works affirmatively to include diversity among its staff and does not discriminate on the basis of race, color, ethnicity, religion, sex/gender identity, sexual orientation, national origin, age, disability, income, marital status, or any other irrelevant dimension of diversity. PPNorCal values collaboration between employees of diverse backgrounds and experiences.

We provide healthcare and education services to 137,000 adults and youth every year at 17 health centers located throughout 20 Northern California counties. Planned Parenthood Northern California offers high-quality, affordable health care to all, regardless of income, insurance, or immigration status. We care. No matter what! Our experienced and caring medical staff gives each patient honest information and personal attention. We provide a full range of services, including birth control, breast exams, cancer screenings, medication and in-clinic abortion, pregnancy testing and counseling, prenatal care, PrEP, and nPEP to prevent HIV infection, STD screening and treatment, vasectomy and infertility services, gender-affirming hormone therapy, and more.