Senior Analyst-Contract Compliance/Revenue Integrity Lead

GENERAL SUMMARY :

Provides analysis and compliant reimbursement expertise to assess payer contract performance for facilities and providers to monitor and enforce all aspects of contract compliance.

Supports the development and implementation of contract compliance analysis initiatives to achieve revenue realization. Provides recommendations to the Managed Care department for revisions to contracts that are performing below forecasted expectations.

Aids the Manager of Revenue Integrity and will serve as a subject-matter expert for the staff of Revenue Integrity in areas of charge master, departmental charging practices, denials, payer policy, CMS regulatory requirements, hospital and professional charging and billing practices.

PRINCIPAL JOB FUNCTIONS :

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Plans and directs the analysis and collection of payment variances.

3. *Identifies, collects, and manipulates data within multiple contract modeling tools, billing systems and databases (e.

g., EPIC, Slicer / Dicer, Workbench, Excel, Power BI) and external sources (e.g., Payer websites) to assess contract performance opportunities and overall impact.

4. Assesses various reimbursement structure options and develops models, reports and tactics to ensure compliance with contracted reimbursement structures.

5. *Prepares reimbursement analyses and financial performance analyses. Performs complex financial reimbursement analysis and models (involving multiple variable and assumptions) to identify root-cause reimbursement discrepancies and trends, and leverages analytics to inform contract compliance efforts as well as negotiation strategies regarding existing contract term risks to share with the Managed Care department negotiators.

6. *Prepares and effectively presents results to Revenue Cycle, Managed Care and Finance leadership, and other key stakeholders, for review and strategic planning activities involving contract compliance.

7. *Acts as the subject matter expert to support the Revenue Integrity Liaisons through the process of setting up CDMs, assisting with assigning the initial CPT code, auditing complete and accurate charging and assisting with the maintenance of the CDM in general.

8. *Leads and assists the Denials Insurance Specialists through the accurate processing and appeal process for denials. Ensures that all options have been investigated before writing off a denial.

Responsible for setting up teams to work with operations, where applicable, to fix the problem causing the denial (Denial Avoidance).

9. *Leads and assists the Revenue Integrity team through the regulatory compliance review, auditing, and implementation involving;

charging, billing, auditing, and maintaining a compliant Revenue Integrity team.

10. Maintains knowledges of industry trends, payer policies and protocols, and revenue cycle operations to support effective contract compliance activities.

11. Prepares routine reports and ad-hoc analyses as required, with ability to accurately reflect actual vs. expected contract performance trends.

12. Leverages reporting and effectively communicates issues to internal department leads, revenue cycle vendors, and managed care payers for meaningful resolution and revenue realization.

13. Becomes certified as an Epic Contract Builder. Works with current Contract Builders to assist with building, maintaining and editing new or existing contracts.

14. *Provides a critical liaison and advocate to identify and rectify contract compliance issues with managed care payers by leveraging relationships and contract expertise.

15. Acts as the point for all Contract Compliance issues.

16. Promotes effective communications between Revenue Cycle, Managed Care, Finance and Payer personnel to ensure consistency and expedite problem resolution to issues.

17. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

18. Participates in meetings, committees and department projects as assigned.

19. Performs other related projects and duties as assigned.

Essential Job functions are marked with an asterisk *. Refer to the Job Description Guide for the definition of essential and non-essential job functions.

Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES :

1. Knowledge of financial healthcare reimbursement analysis, including an understanding of diagnosis and procedure coding, billing practices, and payment methodologies.

2. Knowledge of computer hardware equipment and software applications relevant to work functions.

3. Knowledge of third party and insurance company operating procedures, regulations and billing requirements, and government reimbursement programs.

4. Knowledge of CMS and payer regulatory requirements as it pertains to hospital and professional charging and billing practices.

5. Understanding of and working knowledge of hospital charge master and department charging practices.

6. Understanding of and ability to resolve denials through review of payer policy and contracts with system updates or effective appeal processes.

7. Skill in conflict diffusion and resolution along with the ability to perform crucial conversations with payers or internal leaders with desired outcomes.

8. Ability to problem solve and engage independent critical thinking skills.

9. Ability to understand and translate operational knowledge to identify unusual payer circumstances, trends or activity.

10. Ability to evaluate and enforce negotiated contract rates and terms in collaboration with revenue cycle partners.

11. Ability to lead, coordinate and organize tasks and projects through various complex and challenging situations to completion under time-sensitive deadlines.

12. Ability to maintain attention to detail and concentration for long periods of time.

13. Ability to synthesize, coordinate, and analyze data, find opportunities to automate many simple and repetitive tasks.

14. Ability to maintain a work pace appropriate to given workload, to perform complex and varied tasks and to understand and remember detailed instructions.

15. Ability to make independent decisions and / or exercise judgment based on appropriate information.

16. Ability to recommend operational and management decisions in response to changing conditions.

17. Ability to communicate effectively both verbally and in writing.

18. Ability to establish and maintain effective working relationships with all levels of personnel.

19. Ability to maintain confidentiality relevant to sensitive information.

20. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE :

Bachelors degree in business administration, Finance, Healthcare or related field or equivalent experience required.

Minimum of five years of payer contracting, analytics, revenue integrity, denials management, reimbursement, finance, accounting, or related healthcare industry experience required.

Epic Contract Build Certification and Epic experience is highly desired.