Revenue Integrity Specialist - Care Management

The Revenue Integrity Specialist is responsible for the identification, implementation and monitoring results for all revenue integrity related activities in accordance with department policy.  This includes working with team members to identify causes of denied, rejected, or underpaid claims. The Specialist will take action in correcting errors and by making appropriate referrals that will result in the protection of potentially lost revenue.  The Specialist will track and report causes of denied, rejected, or underpaid claims.  The Specialist will work front end/ concurrent/ and retrospective cases for authorizations.  The Specialist will retrieve, enter and/or disseminate date to receive authorization on concurrent and retrospective case.  Provide information, through team reporting, to the appropriate persons in order to facilitate performance improvement throughout the DCH Health System.

KEY RESPONSIBILITIES / ESSENTIAL FUNCTIONS
 

1. Retrieve and disseminate clinical data to third party payers for authorization/certification of hospital level of care for front end/ concurrent and retrospective certifications
2. Refer adverse outcomes from third party payers to member of the utilization review team
3. Document certification data in Care Management and the Business Office systems. 
4. Identifies opportunities for improvement related to denial management and reports outcomes to Manager monthly.
5. Maintain accuracy of inpatient and outpatient working spreadsheet to include posting of payment, payment date, payer, and action performed.
6. Collaborates with the financial counselors /registration to identify correct payer source
7. Document data in third party payer systems allowable within the revenue integrity skillset
8. Document certification data in Care Management and the Business Office systems. 
9. Works within established processes of the UR to identify denied/rejected/underpaid claims.
10. Performs interventions, appeals, and appropriate referrals to protect and collect lost revenue.
11. Follows-up on inpatient and outpatient interventions and appeals to include calling insurance company, physician’s offices, patients, and related facility departments.
12. Assists manager in developing strategy for overturning appeals and denied claims.
13. Applies critical thinking skills and knowledge to each claim to prioritize and perform interventions in an effort to maximize revenue protection within timely filing.
14. Ensures communications are maintained with all involved departments.
15. Develops a detailed knowledge of the focus and goals of the Utilization Review (UR).
16. Supports the team through follow-up on Inpatient and Outpatient appeals and interventions.
17. Utilizing Compliance 360, Midas, eFR for reports and information related to denials. 
18. Attends division/departmental meetings.
19. .Participates in an annual department project.
20. Arranges for Team meetings and is responsible for minutes as necessary.

1. Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
2. Adheres to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
3. Requires use of electronic mail, time and attendance software, learning management software and intranet.
4. Adheres to all DCH Health System policies and procedures.
5. Provides back up clerical support
6. Performs all other duties as assigned.