Revenue Integrity Specialist I

Job Description:

Baptist Health is looking for a Revenue Integrity Specialist I to join our team. This is a remote position that requires residency in KY or IN

Research denials or audits from all commercial and governmental payors. Performs payor compliance review on accounts to determine medical necessity of services, pre and post service as well as pre andpost billing. Obtains predeterminations, prior authorizations, and retro authorizations when required by
payor. Responds to all account reviews with the best possible efforts to ensure reimbursement,recover outstanding revenue, and prevent future revenue loss while meeting all appropriate payor orgovernment timelines. Recovery efforts include but are not limited to written letter, email, web site, andtelephonic communication.

Essential Duties:

• Reviews all denials or audits on accounts and takes all possible appropriate follow-up action tosecure full reimbursement from payor.

• Reaches out to revenue cycle clinical staff, other departments and physician offices to requestassistance for additional documentation, coding review, letter of medical necessity, etc. whennecessary to successfully appeal an account.

• Follows up on account until full reimbursement recovered or all reasonable appeal options areexhausted.

• Fulfills all payor audit record requests within mandated timeframes; consults with clinical / HealthInformation Management staff as necessary to supplement records to appropriately supportcompliance of medical services rendered.

• Tracks all denial and payor audit follow-up activity and results in appropriate systems and updatessystems in a timely manner in regard to action taken or result received.

• Proactively organizes workflow according to priorities assigned by management. Utilizes softwaretools, work lists or queues, and other tools to balance appropriate intervention with accountreimbursement value and deadlines.

• Maintains tracking of denial and payor audit trends as directed by management.

• Reviews physician orders and diagnoses pre-service and verifies that these are compliant withgovernment and commercial payor coverage guidelines as well as federal guidelines.

• Obtains predeterminations, prior authorizations, and retro authorizations when required by payor.

• Responsibility: Communication, Departmental Collaboration and Trending

• Provides feedback regarding compliance concerns to Manager and / or Director

• Collaborates with other departments and physician offices as necessary to prevent revenue loss, bothin a reactive response to denials and payor audits as well as in a proactive response to changes inpayor and governmental guidelines.

• Communicates trends and unresolved issues to Manager and / or Director.

• Utilizes department best practices to recover or defend reimbursement in the most efficacious mannerpossible.

• Constantly seeks more efficient methods for completing tasks

• Offers suggestions for process improvement to Manager and / or Director.

Minimum Education, Training and Experience Required

• Bachelor's Degree in related field, Practical NurseLicense, or Coding Certification with two years' experience. In lieu of bachelor's degree, five years of healthcare experience required including two years in a revenue cyclerelated area such as registration, patient financial services, or managed care

• Requires knowledge of medical terminology; payor reimbursement guidelines (authorization / notification, medical necessity, and timely filing guidelines); payor denial appeal resolution processes; and managed care contracts. Individuals working with government audits must have a keen understanding of all audit response requirements and timelines.