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Revenue Cycle Optimization Expert

2 months ago

New Haven, Connecticut, United States Yale New Haven Health Full time
Job Summary

We are seeking a highly skilled Clinical Revenue Management Specialist to join our team at Yale New Haven Health. This role will be responsible for performing a wide range of system-wide clinical revenue management activities to prevent insurer denials, enhance revenue, and recover payment for services that have been denied.

Key Responsibilities
  • Follow established protocols for fax review and extract and summarize pertinent clinical information to transmit to payors for reimbursement.
  • Proactively identify potential concerns regarding clinical eligibility for admission and/or continued stay reviews and address with Care Coordination.
  • Coordinate reconsiderations and/or peer-to-peer reviews for concurrent denials, following departmental policy to communicate internally with physicians, care coordination, and utilization nurses.
  • Ensure accuracy of patient status via pre-bill or post-remit CVT, per departmental policy.
  • Identify cases for outlier referral or alternate level of care payment, per departmental policy.
  • Respond to external audits and inquiries, not limited to OIG, IPRO, QIO, and RAC, and document accordingly in EPIC.
  • Establish a system to follow up with payers/managed care organizations regarding outstanding denials and address identified payor issues.
  • Act as a consultant and resource to the financial and care coordination departments regarding utilization insurance and payer issues.
  • Ensure inpatient clinical payor denials are reviewed for appeal potential and file formal appeals with the payors requesting reconsideration of the denied services.
  • Work with the CBS team on inpatient technical denials and precertification issues.
  • Identify trends and consistent barriers and work with the CBS Management Teams and the YNHHS healthcare team to support resolution, intervening when necessary to correct delays and eliminate/reduce negative financial outcomes.
  • Communicate as needed with MDS, payors, and governmental contractual agencies regarding denials and appeals, developing strong working relationships with payors to support collaborative efforts in ensuring hospital reimbursement.
  • Work collaboratively with CBS to support monthly documentation of provider liable dollars, tracking, documenting, and reporting denials and appeals by payor.
  • Track key indicators in the CRM monthly dashboard.
  • Act as a patient advocate to support ongoing medical intervention and treatment, exhibiting awareness of ethical/legal/confidential issues concerning patient care and treatment and supporting the adherence to such practice.
  • Attend Ad Hoc and regular meetings of both the hospital and system Utilization Review and Denial Committees.
  • Perform miscellaneous duties as required or requested.
Qualifications

We are seeking a candidate with a strong background in clinical revenue management, preferably with a minimum of five years of relevant clinical experience in hospital acute care, along with relevant experience in case management, care coordination, and/or utilization management in a hospital or insurance setting. A comprehensive understanding of finance and billing practices is also required.

A current licensure in the State of Connecticut as a Registered Nurse is mandatory, with a Bachelor's of Science Degree. A Master's Degree is preferred. Excellent communication, negotiation, and organizational skills are essential, as well as adaptability to a wide variety of interpersonal encounters with the entire hospital team. Comprehensive understanding in the use of medical records to extract data is required, along with working knowledge of third-party and prospective payment systems. Computer/PC literacy is necessary, with proficiency in Microsoft Office, including Word, Outlook, and Excel. Knowledge of EPIC is strongly preferred. The ability to work collaboratively and independently, as well as flexibility with responsibilities to meet departmental needs, is essential.