REVENUE INTEGRITY SPEC at Covenant Health in Knoxville, TN

Job description

Overview Revenue Integrity Specialist Full Time, 80 Hours Per Pay Period, Day Shift Covenant Health Overview: Covenant Health is the region’s top-performing healthcare network with 10 hospitals, outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year. Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times Position Summary: Performs complex level professional internal analysis related to root cause and resolution of denials for corrective action. Work involves research and analysis of revenue cycle projects for Covenant Health entities as they relate to charging, coding, documentation and billing. Maintains all organizational and professional ethical standards. Works under supervision but with significant latitude for initiative and independent judgment. Responsibilities Integrity Reviews ADR log, Denial Management System reports and payor websites to identify denials and other related issues and proactively address gaps in performance. Reviews information from third party payers relative to claims, charging, coding, and billing in order to ensure compliance with payor rules and claim billing rules. Performs research and analysis of denials related to charges, CPT coding, modifiers and billing processes to recover denied reimbursement as appropriate. Validates that all steps in the appeals process are followed per contractual and regulatory guidelines. Provides education to auditors, nurse and coders in department relative to denials and appeals processes based on final review of denial. Escalates concerns to leadership team as necessary for action. Prepares and packages appeals submissions for ALJ, Independent Review and Binding Arbitration. Prepares and maintains all payor issue lists related to denials as necessary for presentation to third party payors with coordination of leadership team. Researches and validates complaints submitted by Revenue Integrity Auditors related to payor process and handling of appeals with escalation to leadership team. Coordinates payor meetings relative to denial and process complaints for resolution with payors in collaboration with supervisor. Provides on-going feedback to colleagues related to research performed, analysis of denial trends and appeal process gaps. Quality Coordinates with appropriate parties the complete/ partial payment or repayment of the claims as findings are identified that are either over-payments or underpayments. Documents all denial activities in a designated location; reports statistics and identified problems monthly or more urgently if deemed necessary. Develops and ensures compliance with workflows necessary to streamline processes for third party vendors and payors (e.g., Xsolis, Humana, and Advent) in denials management. As necessary, escalates concerns to leadership team. Validates all invoices for third party vendors and prepares them for processing. Works directly with vendors if unable to reconcile. Escalates to leadership team as applicable. Assists with special projects and performs other duties as needed and requested by the Vice President of Patient Account Services, Officer and/or Corporate Manager of Revenue Integrity. Supports, models and adheres to the desired behaviors of the KBOS Constitution for quality which are; celebrate and reward successes, seek out better ways to do our job, set improvement goals and standards striving to meet or exceed them, participate in forming and being part of work teams when necessary and do not say "It's not my job.” Follows policies, procedures, and safety standards. Comp