Revenue Optimization Specialist

1 week ago

Tustin, California, United States SG HOMECARE INC Full time
Job Description

Position Overview:

The Revenue Optimization Specialist plays a crucial role in executing and enhancing charge capture and process enhancement initiatives aimed at maximizing performance and elevating revenue management. This role involves conducting thorough root cause analyses, formulating corrective action strategies, educating internal stakeholders, and monitoring outcomes. Collaboration with the Revenue Cycle Team is essential to implement the Revenue Integrity strategy and enhance revenue outcomes across various departments, financial processes, functions, and interdependencies from patient care delivery to final payment settlements. The specialist is responsible for maintaining the Chargemaster fee schedule in line with established coding practices and regulatory requirements.

Key Responsibilities:

  • Streamlining processes to ensure accurate reporting and reimbursement of services rendered while adhering to all Federal and State regulations, payer policies, and coding standards.
  • Working closely with the Revenue Cycle Team, Compliance, Information Technology (IT), Analytics, and Finance to ensure optimal coding and billing results.
  • Focusing on denial prevention strategies and performance enhancement.
  • Establishing standardized charge capture processes, including daily reconciliation and reporting for all clinical departments.
  • Conducting root cause analyses from charge capture reconciliations, audits, and the Chargemaster to address payer denials, coding/billing discrepancies, and other cash flow impediments.
  • Implementing process improvement strategies to streamline workflows, automate tasks, and optimize technology use.
  • Providing targeted education to relevant stakeholders and recommending best practices for enhancement.
  • Creating standardized reporting for leadership and impacted departments, including a financial activity dashboard that is user-friendly.
  • Monitoring Key Performance Indicators (KPIs) to identify new Revenue Integrity initiatives, track performance improvements, recognize significant trends affecting revenue, and document enhanced performance.
  • Conducting post-implementation audits to verify that system updates and Chargemaster changes lead to appropriate reimbursement.
  • Validating annual pricing updates to the Chargemaster to ensure accuracy and optimize reimbursement within budget constraints.
  • Quantifying metrics resulting from improvements made by the Revenue Integrity Team, such as incremental revenue, cost savings, and Chargemaster compliance.
  • Engaging in special projects and process improvement initiatives.
  • Accurately enrolling or updating payer enrollments across the organization.
  • Managing ERA/EFT/EDI enrollments.
  • Reviewing and resolving W9 and payment address tasks.
  • Following up with insurance payers via phone, email, or online platforms to resolve payer EDI/ERA/EFT issues.
  • Updating systems with HCPC, ICD10, Price Tables, Fee Schedules, etc.
  • Monitoring and rectifying rejections in the EHR System.
  • Performing miscellaneous job-related duties as assigned.

Note: This job description is not exhaustive. Employees may be required to perform other related duties to meet the ongoing needs of the organization.

Minimum Qualifications:

  • Five or more years of experience with hospital billing systems and third-party billing requirements, preferred.
  • Experience in revenue integrity operations, clinical charge capture, charge master, or revenue cycle operations.
  • Proficiency in Microsoft Excel.
  • Understanding of Medicare/Medi-Cal claims processing guidelines.
  • Experience with Brightree EHR or other EHR systems.
  • In-depth knowledge of healthcare revenue cycle practices, procedures, and concepts.
  • Strong analytical and problem-solving skills.
  • Excellent communication, interpersonal, and collaboration abilities.
  • Proficiency in Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and revenue codes.
  • Understanding of DME billing or reimbursement and charge capture operations.
  • Knowledge of CMS regulations and the ability to interpret healthcare guidelines and regulations.

Physical Demands and Working Environment:

The conditions described herein are representative of those that must be met by an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

Environment: Standard office setting; tasks are typically performed without exposure to adverse environmental conditions; frequent interaction with staff and the general public. The role requires the use of a headset and the ability to navigate multiple systems while addressing caller concerns in real-time.

Physical: Incumbents require sufficient mobility to work in an office environment; stand or sit for extended periods; operate office equipment, including a computer keyboard; light lifting, carrying, pushing, and pulling; ability to verbally communicate to exchange information.

Vision: Ability to see in the normal visual range with or without correction; sufficient vision to read computer screens and printed documents; and to operate assigned equipment.

Hearing: Ability to hear in the normal audio range with or without correction.

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