Revenue Integrity Specialist I

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 and post 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 or government timelines.  Recovery efforts include but are not limited to written letter, email, web site, and telephonic communication. 

Qualifications:

• Bachelor’s Degree in a related field, Practical Nurse License, or Coding Certification with at least two years healthcare experience. In lieu of bachelor’s degree, five years of healthcare experience required with at least two of those in a revenue cycle related area such as registration, patient accounting, 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.