Director, Revenue Integrity & Quality - REMOTE

Posted 7 days ago United States Salary undisclosed
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Director, Revenue Integrity & Quality - REMOTE Job Number: 25
Category: Accounting & Finance
Location: Shrewsbury, MA
Shift: Day
Exempt/Non-Exempt: Exempt
Business Unit: Commonwealth Medicine
Department: Commonwealth Medicine - Health & Criminal Justice - W835110
Job Type: Full-Time
Salary Grade: 48
Union Code: Non Union Position -W60- Non Unit Professional
Num. Openings: 1
Post Date: June 15, 2022

Under the general direction of the Senior Director, Finance and Claims Administration, or designee, the Director, Revenue Integrity & Quality (Director) is responsible for management and oversight of a high-quality, effective, best practices revenue cycle integrity program to ensure revenue integrity, and compliance with applicable rules and regulations and all pertaining internal policies and procedures. The Director is responsible for evaluating educational needs for both hospital and professional coding, and for planning, coordinating, and educating providers as needed.

Additionally, the Director is responsible for monitoring the maximization of utilization and bridging processes across the Health Equity programs while working with Operational Site Leadership on corrective actions as needed. The Director is responsible for leading revenue maximization and recovery opportunities as directed by Medicare Rules and other regulations.

This position is also responsible for management of projects related to managing the Quality, Revenue Integrity and Provider Education process improvements. To maintain an effective Quality, Revenue Integrity and Provider Education program the Director will collaborate with various stakeholders, including but not limited to Claims Administration, Patient Care Operations, Finance Administration, New Business Development & Contracting, and other internal and external stakeholders.

The Director is also responsible for oversight of systems and data and for ensuring all Health Equity functions have the system and data resources tools necessary to ensure processes are effective and efficient, in compliance with all regulatory requirements, and accurate data and reporting.

• Overseeing the execution of all aspects of the Health Equity Quality, Compliance, Revenue Integrity, and Provider Education Program, data, and system administration.
• Managing the HCJ Quality, Compliance, Revenue Integrity, and Provider Education Work Plan, including Contract Compliance, Utilization Review, and other claims and financial reports in collaboration with Health Equity Management and Senior Leadership
• Overseeing the systems and data analytics, ensuring all Health Equity functions have the system and data resources tools necessary to ensure processes are effective and efficient, in compliance with all regulatory requirements, and accurate data and reporting
• Spearheading best practices for revenue cycle compliance and integrity based on the latest regulatory guidance
• Training and education on the prevention of coding and billing compliance violations, the promotion of ethical practices, and a commitment to compliance with the Federal and State laws and regulations
• Principal duties include the oversight of key activities related to operations in accordance with the relevant federal, state, and local rules and regulations.
• Leading the development and implementation strategies to identify future legislation, rules, regulations, or documentation standards impacting the program related to revenue cycle compliance; ensuring systems and processes are updated timely and effectively to ensure revenue maximization and integrity
• Providing oversight and coordination of claims quality assurance processes and invoicing activities associated with providing comprehensive healthcare services in accordance with the terms of contracts, and other regulations
• Formulating strategic initiatives to ensure that processes are effectively designed and all providers and key stakeholders receive appropriate education and training related to future coding and billing compliance requirements; and supporting HCJ management, personnel and health care providers in their efforts to comply with all applicable laws, regulations, and policies governing reimbursement activities
• Overseeing and assisting with performance of audits, quality assurance reviews, coding validation reviews, utilization review and case management including physician coding reviews for compliance with Federal, State, and local rules and regulations
• Ensuring revenue integrity risk areas are identified, mitigated and resolved
• Identifying compliance issues/concerns and overseeing the compliance review of patient charts for accuracy of coding, billing, and medical record documentation against the relevant Federal, state and local rules and regulations
• Leading the development of educational and resource materials for provider compliance with clinical documentation, coding and billing compliance; executing the integrity revenue compliance training sessions for Providers
• Overseeing utilization review and case management
• Establishing internal communication of regulatory compliance bulletins related to revenue cycle compliance
• Working closely with Leadership to establish and execute processes that meet regulatory requirements and implement ongoing risk assessments and monitoring techniques
• Preparing written reports to document revenue cycle, coding and billing compliance risk assessments, observations, corrective actions and timeliness, and specific recommendations to improve internal controls and mitigate risks
• Providing direct support as needed to ongoing operation/enhancement of coding, billing, clinical record documentation, reimbursement, legal and financial imperatives/projects and processes that are designed to maximize compliance/quality/revenue integrity
• Ensuring the team adheres to all revenue integrity regulations, policies and procedures, and coaching/training individuals as appropriate
• Providing leadership and recommendations in the ongoing development, effectiveness, and efficiency of the HCJ program revenue capture coding, billing and other reimbursement initiatives driven by Compliance with Regulatory Requirements
• Demonstrating a solid commitment to the delivery of high quality; conducting business with integrity and honesty
• Responsible for overseeing the compliance with Medicare rules, medical coding, CPT, HCPC, ICD-10 & DRG codes, HIPAA, and other regulations in day-to-day activities
• Responsible for building positive relationships, internally and externally, with providers and BOP staff
• Responsible for ensuring staff and providers follow CMS rules, and other applicable regulations, including all contractual requirements
• Establishes quality and compliance KPIs, analytics, various trending, develops workflow procedures, and takes corrective actions where needed
• Provides technical assistance on complex system development, revenue integrity, compliance, and education issues
• Performs other job-related duties as assigned

Bachelor's Degree or equivalent in Business, Healthcare Administration, Information systems or other related field
CPC, Certified Professional Coder; or CHC, Certified in Healthcare Compliance; or CCS, Certified Coding Specialist and/or CIA, Certified Internal Auditor

Minimum of seven (7) years of experience in a health care, claims, revenue cycle, quality, compliance, audit, provider education, System/Data Analytics, or related field
Minimum of five (5) years of experience in supervisory, project management and/or managerial responsibilities required, preferably in a healthcare environment Must have deep subject matter expertise in government billing investigations and audits, health care documentation requirements, coding and billing requirements, and federal and state health care regulatory requirements.
Must have a working knowledge of health care documentation, coding and billing requirements and federal health care regulatory requirements.
Experience working in a complex healthcare system with Health Plan and/or Medical Groups
Ability to demonstrate broad and comprehensive knowledge of theories, concepts, practices, and policies with the ability to use them in complex and/or unprecedented situations across multiple functional areas
Previous experience working in a healthcare setting, with Claims, Billing, and/or other Provider Office Management/Revenue Capture/Claims System
Previous experience with Claims Audit, System Audit, Compliance and Provider Education
Demonstrated ability to build, lead and supervise a team; experience managing a team or functioning as a team lead for a project or group; demonstrated ability to motivate individuals at all levels in the pursuit of common objectives

Master's Degree in Healthcare Administration, or related field, or commissary experience
Project Management Professional (PMP) certification
Previous experience working in healthcare insurance/government contracts and physician office billing practice

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