Ensures compliance with Federal, internal and corporate policies; practice and procedure development. Implements an audit process including identifying opportunities for improvement and development of action plans. Provides support and education to ancillary and clinical departments. Assists RAC Coordinator on denials to ensure all claims denied due to medical necessity issues are processed through the denial management spectrum including submission of documentation. Participate in other special projects as directed.
JOB SPECIFIC ACTIVITIES:
1. Maintains consistency with Administrative and Departmental policies with appropriate behavior, dress, attitude, attendance, confidentiality, professionalism, and reliability.
2. Develops and implements an audit process to include the review of billing and medical coding and documentation. This process is to include a biweekly review of a sampling of admissions. Each biweekly review is to be completed by the end of the week with findings and recommendations reported to appropriate level of management.
3. Develops and completes focus reviews as indicated.
4. Acts as a resource to Commercial Auditor.
5. Documents all audit processes with written findings and/or plan of action.
6. Works with Department Managers in the development and implementation of a plan of action to ensure that all recommended or required changes including training of clinical staff are made within set time frame. Outcomes are to be fully documented with written outcomes reported to appropriate levels of management.
7. Acts as a team leader for Denial Management process including the scheduling of biweekly meetings, maintaining of meeting minutes and maintaining and ongoing action plan. This includes acting as a liaison between Clinician Departments, Information Systems, HIM, Business Office Management and Admissions. Provide monthly written reports that include outcomes and progress to appropriate level of management.
8. Monitoring denial management process including the maintenance of denial management log ensuring that targets are met.
9. Submits all medical documentation in appropriate time frame ensuring successful appeal of claims.
10. Provided guidance to Management level for departments when clinical issues are identified that may have caused denial of payment based on medical necessity. Acts as resource to department managers for research of clinical issues and ways to avoid denials. Works with Medical Director to disseminate information to medical staff regarding documentation and clinical issues denials. Makes independent decisions for appealable clinical issues and notifies appropriate individuals when appeal is not applicable and no evidence for medical criteria. Provides written notification to medical staff when poor utilization practice has caused a medical necessity denial.
11. Works to provide charge master coordination under direct supervision on Revenue Director. Responsible for the maintenance of the Charge Description Master that enables hospital to bill on the appropriate claim forms. This position works closely with clinical departments to maintain existing charge codes, the development of new charge codes for new services, and ensure that the CMS is compliant with federal and state regulations. Applies/keys new information from yearly and quarterly reviews to update charge master.
12. Researches changes for department Managers and Directors from CMS and other payor sources regarding reimbursement potentials for reimbursement liabilities. Researches reimbursement and assists department Managers and Directors with appropriate pricing of services and supplies using CMS fee schedule information and CHRISTUS St. Michael Business Management Service Policy (supply mark-up formula). Coordinate with Coding Compliance, Patient Accounting and Business Office Manager regarding issues affecting charge master maintenance and compliance to state and federal guidelines and issues that may impact charging and billing. Works with Business Office Manager to distribute state and federal publications affecting hospital billing, compliance, charge master issues and documentation. Researches issues as they arise on an on-going basis as needed to assist Coding Compliance and Business Office Manager.
13. Assists Department managers with charge master revisions due to changes to CPT manual and Medicare bulletin coding changes. Ensures that all changes are made within timeframe.
14. Monitors Medicare bulletins and provider manual updates on a weekly basis. Notify appropriate level of management to ensuring that all necessary changes are made within appropriate timeframe.
15. Acts as the Charge Master Team Leader including scheduling meetings, recommending policy and procedure changes and maintaining meeting minutes.
16. Provides research and prepares other special projects as directed.
17. Coordinates with IS and Patient Accounting with new department build using ID-1 and ID-2 test. Assists with testing STI's. Applies charge master system price increases as instructed from Administration. Assures calculation for all departments prior to price change by testing in ID.2.
18. Coordinates use of charge master maintenance tools with Business office, department Director and Managers. Acts as a hospital resource for departments with questions regarding charge master.