Overview
The Revenue Integrity Coordinator (RIC) is responsible for the identification, implementing and monitoring results for all revenue integrity related activities in accordance with department policy. This includes working with team members to identify causes of denied, rejected, or underpaid claims. The RIC will take action in correction errors and by making appropriate referrals that will result in the protection of potentially lost revenue. The RIC will track and report causes of denied, rejected, or underpaid claims and work front end/concurrent/and retrospective case for authorizations. The RIC will lead the team to retrieve, enter, and/or disseminate date to receive authorization on concurrent and retrospective cases. The work of the RIC will include providing information, through team reporting, to the appropriate individuals to facilitate performance improvement throughout the DCH System. The RIC role will provide oversight of the team focus on preventing and reversing denials.
Responsibilities
Develops detailed knowledge of and drives the focus and goals of Utilization Review (UR)
Retrieves and disseminates clinical data to third-party payers for authorization/certification of hospital level of care for front end/concurrent and retrospective certifications
Provides orientation, direction, and ongoing mentoring/coaching of the Care Coordination Clerk (MOONs; IMMs; Condition Code 44’s, Kepro Requests for Medicare appeals, entering moms & babes on JIVA & MIDAS, etc)
Refers adverse outcomes from third-party payers to appropriate member of the UR team
Identifies opportunities for improvement related to denial management and report outcomes to the URM at least monthly
Works with the DCH financial counselors and registration to identify correct/accurate payer source
Documents data in third-payer payer systems allowable within the revenue integrity skillset
Documents certification data in Care Management and Business Office systems
Maintains accuracy of inpatient and outpatient working spreadsheet to include posting of payment, payment date, payor, and action performed
Works within established processes of UR to identify denied/rejected/underpaid claims
Performs interventions, appeals, and appropriate referrals to protect and collect potentially lost revenue by following up on inpatient and outpatient interventions and appeals to include calling insurance companies, physician’s offices, patients, and related DCH departments
Maintains spreadsheet of criteria utilized by payers to deny claims or oversees this document
Provides oversight for authorizations and denials and forwards to Medical Records
Assists UR Manager in developing strategies for overturning appeals and reversing denied claims
Applies critical thinking skills and knowledge to each claim to prioritize and perform interventions to maximize revenue protection within timely filing
Ensures that communications are maintained regarding revenue integrity with all involved departments
Supports the team through follow-up on inpatient and outpatient appeals and interventions
Utilizes Compliance 360, MIDAS, and eFR for reports and information related to denials
Attends departmental meetings and assists the URM in educating the UR team on denial prevention
Participates in annual departmental project and assists in leading the team in UR denial prevention
Assists URM to arrange team meetings and may be responsible for minutes as necessary/requested
Maintains performance, patient and employee satisfaction and financial standards
Adheres to DCH Behavioral Standards including creating positive relationships with patients/ families, and colleagues
Provides level of care reports to Medical Records
Provides back-up clerical support as needed
DCH Standards:
- Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
- Performs compliance requirements as outlined in the Employee Handbook.
- Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
- Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
- Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
- Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
- Requires use of electronic mail, time and attendance software, learning management software and intranet.
- Must adhere to all DCH He