Director, System Revenue Integrity (Revenue Cycle Operations)

PURPOSE OF POSITION :

Develops and executes the strategic vision for system-wide Hospital, Professional and Ancillary Services Revenue Integrity functions within Cape Cod Healthcare (CCHC's) Revenue Cycle organization. Provides leadership and oversight of key operational and financial decisions pertaining to all underlying functions. Functional areas that report to this position include Charge Description Master ("CDM") maintenance, charge capture and reconciliation related functions, payment variance, audit and appeals management, and denials management process audit review. Additionally, this role is responsible for defining efforts and focus areas to address denial root cause issues. Confirms that metrics are met, charge entry rates and accuracy rates are achieved to meet yearly revenue goals.

PRIMARY DUTIES AND RESPONSIBILITIES :

• Lead the establishment and implementation of Key Performance Indicators ("KPIs") for revenue integrity functions; ensure the implementation of action plans where performance is not meeting expectations; review KPI expectations annually and adjust appropriately; recognize areas of excellence.
• Develop, implement, and oversee effective and consistent operational policies, processes, tools, and educational materials within all Revenue Integrity functional areas
• Oversee the operational performance of a system-wide, service line-based Charge Review program dedicated to identifying charge capture issues / improvement opportunities to minimize revenue leakage, through the use of technology enablers and proactive internal audits / reviews of charging practices.
• Ensure that the CDM is compliant with regulatory and payer requirements and that all services provided have an established charging and reconciliation methodology.
• Ensure Revenue Integrity employees across all functions comply with established policies, processes, and quality assurance programs.
• Identify potential process improvements in charge capture functions, and lead the design and implementation as required.
• Monitor and facilitate service level agreements ("SLAs") between Revenue Integrity operations and other related functions within both Revenue Cycle and Clinical operations. This includes confirmation that charge review queues / requests are managed appropriately.
• Build strong relationships and facilitate productive communication between key Revenue Cycle stakeholders, including peer leaders of Revenue Cycle services and core support departments (e.g., human resources, IT, finance).
• Develop, implement, and manage efficient and effective operational policies, procedures, processes and performance monitoring across all revenue integrity functions.
• Ensure audit of denial management processes occurs consistently and coordinate with peers across the revenue cycle organization, and with other related stakeholders, to identify trends and implement denial prevention / recovery programs.
• Oversee, measure, and report ongoing financial and operational performance of Revenue Integrity, audit and appeals outcomes and denial management across CCHC.
• Support CCHC strategic initiatives that require involvement from revenue integrity functions as required.
• Assess direct reports' performance on a consistent basis and provide feedback to reward effective performance and enable proactive performance improvement steps to be taken.
• Lead the establishment and implementation of Key Performance Indicators ("KPIs") for audit and appeal functions; ensure the implementation of action plans where performance is not meeting expectations; review KPI expectations annually and adjust appropriately; recognize areas of excellence.
• Develop reporting to support the transparency of audit and appeals outcomes
• Identify potential process improvements within the audit and appeals workflows and lead the design and implementation as required.
• Develop and monitor productivity metrics for all Revenue Integrity functional areas
• Oversees payment variance team members and workflows
• Seeks opportunities to address and remedy system and / or payer related issues causing payment variances
• Develop reporting to identify and monitor root cause payment variance issues
• Reports payment variances to executive leadership
• Challenges current working practices; identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization's culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.

EDUCATION / EXPERIENCE / TRAINING