The Revenue Integrity Director develops, maintains, and reports on the charge description master (CDM); ensures data and charge integrity between the CDM and hospital departments; researches coding and revenue reporting requirements and uses strategic pricing applications to maximize reimbursement and ensure regulatory compliance. The position will assure accurate charge design, build, validation, testing and quality assurance for all changes to the CDM, electronic and paper charge forms, and charge systems applications. This position reports to the Vice President of Revenue Cycle and supervises the CDM Coordinator.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
Responsible for developing, maintaining and enhancing the CDM in a manner that supports PCH's Coding and Compliance Monitoring Plan.
- Maintains the CDM by incorporating new charges/services identified by the departments, third-party changes, CMS regulations, federal and state specific coding updates.
- Performs a detailed, annual review of the CDM that includes identifying CPT and HCPCS codes that have been deleted, added, or replaced; assigns CPT and HCPCS specific codes when appropriate, identifies description changes, ensures the nomenclature reflects the procedures performed, and maintains an audit trail of all changes.
- Researches and resolves CPT and HCPCS codes, revenue codes, and other issues.
- Collaborates with the Office of Business Integrity by verifying adherence to charge posting policies and procedures, ensuring compliance with required governmental laws, regulations, contractual requirements, standards and practices both related to the systems charge master.
- Keeps abreast of changing industry requirements and regulations regarding acceptable documentation and billing practices by reviewing Federal Register, fraud alerts, OIG advisory opinions and other relevant publications. Communicates changes to impacted leaders and provides education on such changes.
- Establishes and performs periodic billing/claim audits based on CDM complexity and risk.
- Responds to outside compliance questions, complaints, and inquiries related to CDM items.
Partners with departments and executive leadership to recommend and communicate additions, changes, opportunities, and audit results.
- Coordinates meetings with department managers, staff and/or physicians regarding new program and procedure developments, equipment acquisitions and validation of inactive codes. Serves as a resource to hospital departments for implementation or regulatory questions.
- Leads Revenue Integrity Committee. Communicates CDM changes to the hospital departments and administration, revenue cycle, and others who are impacted by the change.
- Monitors revenue and usage reports daily for anomalies and researches issues. Reviews late charge reports for optimization and efficiency opportunities. Completes and provides other management reports as requested. Routinely reviews revenue recognitions processes across the organization through facilitation of Revenue Review Team.
- Works with Managed Care to recommend terms and conditions and charge increases with consideration of improving reimbursement.
- Distributes correspondence of third-party requirements for coding changes to departments for review of the impeding changes.
- Provides assistance, coordination and education on Revenue Integrity related issues.
Provides technical assistance and oversight for charging of new services and strategic pricing initiatives. Identifies services that are reimbursable, but not being coded.
- Facilitates annual strategic pricing initiative.
- Determines charge and charge attributes for new services and products.
- Identifies services that are reimbursable but are not being coded; reviews, assigns and validates revenue codes. Coordinates adjustments to the current market pricing position to meet organizational goals.
- Performs miscellaneous job related duties as requested.