This employee analyzes financial and claims data to optimize processes and reporting, improving financial performance that includes incorrect billing and underpayments, which will in turn improve collections. This requires streamlining processes for accuracy and reducuction in delays, analysis of denials, and adjustments to identify root causes, as well as quickly identify developing trends.
- Use revenue data to identify process improvements throughout the business while ensuring regulatory compliance
- Ownership of product, item, and HCPC code databases
- requires cleanup to bring them up to date, along with periodic updates to maintain
timeliness and accuracy, including advising the Payor Tables team of changes
- requires cleanup to bring them up to date, along with periodic updates to maintain
- partner with Procurement and Operations to establish a process to review/accept new codes
JOB FUNCTIONS
- Prepares and analyzes revenue cycle data to identify trends, root causes for denials, and adjustments, along with opportunities for operational improvements
- Creates processes and reports with analysis and actionable insights to CRO and leadership
- manages the reconciliation and build of new products into the product catalog and billing system
- Works with management to develop and implement new policies and procedures
- Collaborates with cross functional departments to review current processes, identify inefficiencies, analyze root causes, and implement scalable improvements
- Works closely with CRO and other stakeholders to support revenue optimization objectives
- monitors and presents performance trends and strategic insights
- Analyzes financial and operational accounts to identify miscoding, underpayments, investigates root causes, and recommends corrective actions to recover lost revenue and prevent recurrence
- Compiles and analyzes data related to coding, claims edits, rejections, denials, and write-offs to identify trends and communicate findings and opportunities for improvements to leadership
- Oversees the daily execution and quality control of adjustment requests, ensuring adjustment codes and supporting documentation are justified and fully aligned with payer guidelines and internal policies
- Analyzes adjustment request data to identify root causes of recurring issues and collaborates with management and revenue cycle leaders to recommend corrective strategies
- Acts as subject matter expert and consultative resource for leadership on issues related to coding, claim adjustments, denials, and underpayments to support decision making and issue resolutions
- Compiles and communicates trends and identifies opportunities to reduce coding errors, claim edits, clearing house rejections, denials, and write-offs
- Manages resolution of high-complexity coding and/or adjustment cases, ensuring thorough documentation and effective communication with all stakeholders
- Performs reviews and validates adjustments to ensure all due diligence (including payment corrections) are processed accurately and efficiently
Education
- Bachelor's Degree in related field, Required
Work Experience
- At least 5 years of relevant management experience, Required
- Payor contracts
Knowledge, Skills, and Abilities
- Strong analytics and problem-solving
- Excellent communication and team collaboration
- Healthcare billing, coding practices, and industry standards and regulations
- Proficiency in relevant software and systems such as MS Excel, including data manipulation, pivot tables
- MS Word and PowerPoint
Licenses and Certifications
- Coding certification