Director of Professional Revenue Integrity

Job Profile Summary

This position is responsible for overseeing and managing all aspects of professional service charges to secure the organization’s revenue integrity. The Director, Professional Revenue Integrity is accountable for the execution of the leadership, development, vision, operational and fiscal management of the professional services revenue integrity department. Creating a culture of development, collaboration, and continuous improvement is essential in this position. This position is responsible for establishing department level productivity and quality standards. This position plans and oversees the completion of a full range of department activities including administrative and technical aspects of professional services revenue integrity supporting the design and implementation of effective systems to ensure accurate, compliant, and timely charging. This position maintains a thorough comprehension of revenue cycle processes including Charge Capture, Charge Reconciliation, Data Analytics, Performance Optimization, Pricing, Reimbursement and Professional Billing. Partnering with leadership in Revenue Cycle, Clinical Departments, Networking, and Finance is essential to revenue performance across the Physician Enterprise. This leader maintains current knowledge of regulatory requirements, billing guidelines, and industry standards of pricing, including market conditions, government rates, local demographics, and economics. This position typically reports to the Vice President, Physician Enterprise Revenue Cycle.

MINIMUM QUALIFICATIONS

Education: Bachelor’s degree in Healthcare Administration, Business Management, Accounting or related field preferred.

Licenses/Certifications: Certification(s) preferred:

• Certified Professional Coder (CPC)

• Certified Medical Coder (CMC)

• Epic certification such as ARCR: Resolute Professional Billing Claims and Billing Readiness

• Project Management Professional (PMP)

Experience / Knowledge / Skills:

Ten (10) years of Physician/Professional Billing experience with at least five (5) years in a management level position for a large health system required.

• Extensive knowledge and experience with Epic EMR system, specifically with EPIC Resolute Billing with a large health system.

• Experience in Charge Capture, Charge Reconciliation, Charge Pricing, Charge Routing, and Reimbursement.

• Comprehensive understanding of healthcare billing and coding systems (e.g., HCPCS, ICD10).

• Proven analytical ability, organizational and critical thinking skills to systematically analyze problems based on data analytics and devise appropriate courses of action.

• Proven track record of implementing business strategies while effectively managing details of complex, multi-faceted projects.

• Must possess strong communications skills to successfully collaborate and interact with internal/external team members, colleagues, and contacts of varying levels or backgrounds.

• Advanced proficiency in Microsoft Excel and other Microsoft Business applications (i.e. Word, PowerPoint)

• Ability to supervise and train employees, including organizing, prioritizing, and scheduling work assignments to meet timelines; requiring leadership and mentoring skills to support department and employee development.

• Ability to make independent decisions when circumstances warrant; make prompt and accurate judgments regarding other office duties.

PRINCIPAL ACCOUNTABILITIES

Oversees all facets of professional services revenue integrity processes to achieve and exceed best practice benchmarks.

• Partners with senior leadership to establish and maintain industry-leading best practices to for overall revenue integrity including professional services coding and clinical documentation. Enhances financial performance by implementing process improvements, optimizing charge capture and reconciliation, and maximizing revenue to achieve optimal reimbursement for services rendered.

• Monitors governance of daily charge reconciliation procedures and engages departments in maintenance.

• Provides support and pricing methodology guidance through fee schedule maintenance.

• Advises Networking on payer trends and adjudication procedures as necessary. Monitors work queues and reports and actively seeks for areas of opportunity, deficiencies, and improvement strategies to minimize hold lag and improve timely charge creation.

• Promotes a data-driven approach to prioritize actionable improvements resulting from root cause denial analysis, delivering prevention and error reduction, involving assessment of system edits, provider education, and clinic management feedback.

• Develops strategy, specific goals, objectives, budgets, and performance standards for professional services revenue integrity with intent to improve patient care and increase growth and profitability.

• Delivers prompt and direct communication to key stakeholders regarding project findings, revenue risks, and actively participates in committees, project teams, and performance management initiatives, effectively communicating with all levels of managers and staff.

• Ensures professional services revenue integrity teams follow department protocol, Policies and Procedures, and comply with Federal, State, and payer regulations.

• Establishes and maintains cooperative relationships with all applicable roles within revenue integrity including medical staff, leadership, Operations and Practices to serve as an internal consultant on revenue integrity related issues, collaborating through performance metrics, shared results, feedback, and solutions.

• Directs and reviews analyses, reports, key performance indicators, and operational metrics while also managing productivity and quality of output from the team through data, usage, and reports. • Ensures the recruitment, training, and retention of motivated, competent managers, supervisors, and analysts; establishes goals and standards for performance appraisals.

• Oversees management of appropriate personnel, providing recommendations for hiring, promotion, salary adjustment and personnel action.

• Guides individuals and groups toward desired outcomes, setting performance standards and delivering leading quality services.

• Directs management team in staffing and productivity management, while providing communication to relay department updates, organizational activities, financial performance, educational opportunities, interdepartmental activities, and quality improvement activities to management team and department associates.

• Provides, oversees, and/or coordinates the provision of training for new and existing staff on applicable operating policies, protocols, systems and procedures, standards, and techniques.

• Responsible for monthly/quarterly meetings with leadership to discuss key performance indicators, actionable improvements to meet PKIs and department specific growth and development influencing revenue cycle operations.

• Complies with HIPAA and all relevant laws, rules, regulations, and accreditations requirements.

• Ensures safe care to patients, staff and visitors; adheres to all policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.

•Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences.