Director of Revenue Cycle & Revenue Integrity

ATLANTICARE                                             

_____________________________________________ROLE DESCRIPTION

TITLE:  Director, Utilization Management and Revenue Integrity
JOB CODE:  1281	EXEMPT:   NON-EXEMPT:	DATE: 12/07	REVISED: 08/23

 

POSITION SUMMARY
This position is responsible for the Utilization Management department and the Revenue Integrity department, to include the oversight and maintenance of the charge description master (CDM). The Director of Utilization Management and Revenue Integrity will lead and direct the Utilization Management staff to ensure leading practices are in place for the collaboration with medical providers to support the accurate level of care placement for hospital patients. They will interact with clinical departments and management regarding compliance issues, documentation, potential denials, pricing and CDM issues. This position will be responsible for the overall quality of work, productivity and developing standards to ensure integrity. They will preside over administration, budgeting, forecasting, planning, HR management and RI/billing compliance.

This position assists the AVP, Revenue Cycle with the planning of strategic revenue cycle processes and implements, as necessary.

Additionally, this position will lead the functions related to surgical case precertification, performing payer defense audits and the coordination and development of appeal letters, to include monitoring outcomes and understanding performance improvement opportunities.

QUALIFICATIONS

• EDUCATION: Bachelor's degree in business, healthcare administration or related field required. Master's degree in business, healthcare administration or related field preferred.
• EXPERIENCE: At least 7 years of revenue cycle management experience with at least 5 years in a management capacity in a health system setting, preferably of similar size or greater and similar level of complexity. Increasing scope of responsibility demonstrated over time. Four or more years of experience with hospital charge description master maintenance, auditing and billing compliance, including reimbursement, charge entry, coding and charge description master maintenance.
• LICENSURE, CERTIFICATION AND/OR REGISTRATION: Registered Nurse (RN), Certified Coding Specialist (CCS), Certified Professional Coder (CPC) or Certified Revenue Cycle Representative (CRCR) is preferred.

 
SKILLS AND QUALIFICATIONS:

• Collaboration: Demonstrated experience fostering strong stakeholder relationships necessary to build an effective and efficient RI program and masterful at conflict resolution and engaging listeners.
• Business: Knowledge of all aspects of healthcare revenue cycle functions, including registration, coding and documentation standards; billing and collection processes; and the application of clinical appropriateness criteria to monitor appropriateness of admissions and continued stays.
• Regulatory: Knowledge of CMS local, state and federal regulatory requirements related for compliant charge capture, utilization management and billing practices.
• Business Analytics: Ability to ensure that data and analytic challenges are understood and resolved by the team and to define and leverage data for management decision making.
• Facilitator: Utilizes the art of the question to create and cultivate new possibilities that stimulate new thinking. Is fluid and flexible versus rigid.

PERFORMANCE EXPECTATIONS

Leadership

• A proven leader with significant revenue cycle experience to lead the integration of all Utilization Management and Revenue Integrity services.
• Strives to identify compliance risk through department-led risk assessments, system monitoring and periodic audits. Reports any identified violation to Legal Services and Corporate Compliance departments.
• Ensures immediate action is taken on any issues identified through a self-assessment or by Legal Services or Corporate Compliance.
• Proven record in leadership, mentoring and development of previous direct reports.
• Demonstrates a desire to provide guidance to help direct reports achieve growth, established goals and desired outcomes.
• True "change agent" able to lead diverse groups in implementing new programs and ideas. A courageous, innovative and energetic individual with a "can do attitude" that can inspire an organization to do its best and stay the course even in difficult circumstances.
• Exhibits strength of character to champion risk taking, a self-starter and self-motivated.
• A true collaborator who can influence by actively listening and bringing multidisciplinary teams (clinical operations, care providers, administration, etc.) together.
• Prepares staff to recognize and mitigate risks brought on by organizational changes.
• Serves as the transformation advocate to generate enthusiasm and excitement for the change.
• Serves as a key member of the Revenue Cycle leadership team and contributes broadly across the organization at all levels.
• Builds and nurtures collaborative supporting relationships with the AtlantiCare executive team, clinical chairs, faculty, clinicians and other leaders across the health system. Encourages, promotes and advocates for staff to ensure integration of new processes across all departments.
• Demonstrates advanced leadership in the areas of:
  • Patient-centric revenue cycle management processes
  • HFMA MAP metrics and measurements and industry-leading practices
  • HIPAA compliance
  • Technology integration to improve operational efficiency
  • Regulatory compliance
  • Reimbursement methodologies
  • Team building and executive collaboration
  • Human resources
  • Financial management
  • Planning
  • Directing
  • Continuous quality improvement
  • Institutional support and representation (external)

Operations Management

• Performs analyses, identifies trends and validates compliance as related to fiscal activities generating additional revenue, reducing bad debt expense and charity write-offs, and overall expense reduction.
• Provides oversight for revenue monitoring and serves as a liaison for revenue-generating departments.
• Develops management reports for distribution and review, incorporating leading practice benchmarks.
  • Completes charge-related audits and actively engages in the creation and monitoring of appeal letters due to denials.
  • Ensures medical necessity of hospitalized patients utilizing level of care screening criteria and referrals to secondary medical reviewers, as applicable.
  • Performs trending of denials and works to understand root cause analysis, working collaboratively with key stakeholders to implement resolutions.
  • Establishes and maintains an accurate charge description master (CDM) to include researching regulatory, coding and billing guidelines; researching insurance contracts; and coordinating updates and revisions when applicable.
  • Works with the revenue-producing departments to ensure the ongoing coordinated consistency of the CDM, including accurate descriptions, coding, additions, deletions, pricing, charging methodology and any other changes.
    • Reads, interprets and distributes payer coding and reimbursement information to all departments affected to ensure regulatory compliance.
  • Works collaboratively with clinicians, auditors, revenue cycle services and information services to understand services provided to explore and capitalize on opportunities for enhanced revenue integrity (minimize charge leakage, maximize compliant reimbursement).
  • Works with Finance to perform applicable analyses to understand net revenue effect of proposed chargemaster changes. Coordinates scheduled pricing updates and facilitates all software file updates.
  • Develops and implements best practice revenue management policies and procedures that guide CDM and audit performance and supports defined service level and key performance indicator metrics.
  • Ensures that operational processes and technology are aligned and integrated to enable effective and efficient realization of the organization's full revenue potential.
  • Engages information services to remediate and/or enhance system functionality to provide improved decision support for denials management.

Regulatory

• Acts as source of reference for enterprise on regulatory, reimbursement or billing changes. Develops and implements processes to maintain and support compliance with federal and state regulations.
• Maintains a working knowledge of revenue cycle process to aid in the implementation of regulatory standards that assist the health system in cash collection, while accurately complying with billing guidelines.
• Monitors compliance with corporate, federal and state guidelines, to include review of commercial bulletins for HCPCS/CPT code changes and additions and billing unit rule changes.
• Serve as liaison with outside government entities (along with Legal and Compliance) regarding audits by RAC, MAC and/or OIG.

Training

• Responsible for development and presentation of year-end education of key stakeholders on regulatory changes that will affect revenue for the enterprise.
• Assists clinical and operational departments in understanding, identifying and remediating key operational issues leading to revenue leakage.
• Enhances the overall education level by creating a plan to keep staff cutting-edge when it comes to their job functions.

Staff Management

• Oversees the development and execution of onboarding, training and education programs for Utilization Management, Revenue Integrity, CDM and audit staff to ensure talent development and optimal performance.
• Promotes a team concept reflecting the mission, vision and philosophy of the health system.
• Builds, champions mand sustains a diverse work environment and culture in alignment with the mission of the organization.
  • Ensures recruitment and retention of talented staff in accordance with the standards set forth by the health system.
  • Creates and promotes an environment of leadership and direction, providing subject matter expertise in all areas related to revenue cycle management.

Other

• Coordinates with all CDM and audit functions in compliance with the standards of the health system leadership, medical staff and outside regulatory/accreditation agencies.
• Builds and integrates customer-centric revenue integrity and training processes and ensures a strong culture of customer service and outstanding performance.
• Assesses and responds to organizational and customers' needs with innovative programs to ensure customer satisfaction.

WORK ENVIRONMENT
Potential for exposure to the hazards and risk of the hospital environment, including exposure to infectious disease, hazardous substances and potential injury. This position requires desk/computer work for a majority of the time. Requires some walking and standing and occasional lifting up to 20 lbs.

REPORTING RELATIONSHIP
This position reports to the Director of Patient Accounting and supervises the manager for Utilization Management, the manager for Medical Audit, and the supervisor for Medical Audit.

The above statement reflects the general details considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.