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Healthcare Revenue Cycle Auditor

2 months ago

Chicago, Illinois, United States PCG INTERNATIONAL INC Full time
Job Description

Overview:
PCG International Inc. is a prominent entity in the financial, recovery, insurance, and healthcare sectors. Our commitment to delivering innovative solutions and maintaining high standards of excellence has established us as a reliable partner in the industry. We utilize advanced technology and a data-centric approach to achieve exceptional outcomes for our clients.

Position Summary:
The ideal candidate will possess substantial experience in healthcare revenue cycle management, with a specific focus on analyzing EDI transactions and ensuring accuracy in zero balance across diverse financial systems. This role demands strong analytical capabilities, meticulous attention to detail, and the ability to work collaboratively with cross-functional teams to enhance revenue cycle operations.

Key Responsibilities:

  1. EDI Transaction Analysis:
    • Examine electronic claims submissions, remittance advice, and other EDI transactions to detect discrepancies, errors, and trends.
    • Collaborate with IT and revenue cycle teams to resolve EDI issues promptly.
    • Establish and maintain EDI performance metrics to track transaction volume, rejection rates, and turnaround times.
  2. Zero Balance Process Management:
    • Supervise the zero-balance reconciliation process to guarantee accurate posting of payments, adjustments, and denials.
    • Implement best practices and controls to reduce zero balance variances and enhance revenue integrity.
    • Work closely with billing and collections teams to investigate and rectify discrepancies related to zero balance accounts.
  3. Revenue Cycle Analysis:
    • Conduct thorough analysis of revenue cycle data to uncover opportunities for process improvement, cost reduction, and revenue enhancement.
    • Create reports and dashboards to present key performance indicators (KPIs) associated with EDI, zero balance, and overall revenue cycle performance.
    • Collaborate with stakeholders to formulate and execute action plans based on analytical findings.
  4. Compliance and Regulatory Adherence:
    • Stay informed about healthcare regulations, payer policies, and industry trends pertinent to EDI transactions and revenue cycle management.
    • Ensure compliance with HIPAA, HITECH, and other relevant regulations governing electronic transactions and protected health information.
    • Participate in audits and regulatory reviews concerning revenue cycle processes and EDI transactions.
  5. Team Leadership and Collaboration:
    • Provide mentorship and guidance to junior analysts within the revenue cycle team.
    • Encourage a collaborative working environment by effectively communicating with cross-functional teams, including IT, finance, billing, and compliance.
    • Lead or engage in revenue cycle improvement initiatives and projects.
    • Stay updated on the latest industry regulations and coding standards related to healthcare revenue cycle management.
    • Manage projects focused on accurately matching 835 remittance advices with corresponding 837 claims submissions.

Additional Responsibilities:

  • Extract and analyze 837 transaction files containing claims data submitted to Medicare.
  • Match claims submitted to Medicare with corresponding payments received to verify accuracy.
  • Conduct thorough reviews of claims to ensure compliance with Medicare billing regulations and guidelines.
  • Identify and investigate discrepancies or errors in billing, such as overpayments, underpayments, or billing inaccuracies.
  • Collaborate with internal teams to resolve billing discrepancies and ensure timely reimbursement.
  • Document audit findings and prepare reports detailing any discrepancies or errors found during the audit process.
  • Stay updated on changes in Medicare billing regulations and guidelines to ensure compliance.
  • Provide recommendations for process improvements to enhance billing accuracy and efficiency.

Requirements:

  • Bachelor's degree in healthcare administration, finance, business, or a related field.
  • A minimum of 3 years of experience as a revenue cycle analyst with a focus on EDI transactions and zero balance reconciliation (835/837).
  • Strong understanding of healthcare billing, coding, and reimbursement methodologies.
  • Proficiency in utilizing revenue cycle management software and EDI transaction platforms.
  • Excellent analytical and problem-solving skills, with the ability to interpret complex data sets.
  • Strong communication skills, both verbal and written, with the ability to effectively interact with stakeholders at all levels.
  • Demonstrated leadership capabilities and experience in leading cross-functional teams.
  • Certified Professional Coder (CPC) or Certified Revenue Cycle Specialist (CRCS) certification preferred.
  • Knowledge of healthcare compliance regulations and industry standards.
  • Ability to adapt to changing priorities and work effectively in a fast-paced environment.

Additional Qualifications:

  • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification.
  • Experience with Medicare Advantage and other government healthcare programs.
  • Knowledge of ICD-10, CPT, and HCPCS coding systems.
  • Experience working in a healthcare consulting or advisory role.