Documentation Integrity Analyst

The Revenue Integrity Analyst is responsible for performing specialized second-level review of medical records for vascular and other assigned high-risk services. The role evaluates clinical documentation, coding requirements, and payer coverage criteria to determine whether the medical record supports the ordered service; coordinates resolution of documentation deficiencies; and supports audit readiness, regulatory compliance, provider education, and continuous process improvement.

Perform second-level, pre-service review of vascular and other assigned high-risk cases against applicable Medicare and commercial payer policies, NCDs, LCDs, coding requirements, and regulatory and audit expectations. Validate that the physician order, progress notes, and supporting clinical documentation are complete, consistent, and sufficient to establish medical necessity.

Identify missing, incomplete, inconsistent, or unsupported documentation and determine the appropriate next step in accordance with established workflows. Escalate cases that do not support coverage requirements and facilitate appropriate resolution prior to service or billing whenever possible.

Coordinate with ordering providers and their offices to obtain missing medical records, clarify documentation, and support timely resolution of cases requiring additional information.

Collaborate with clinical operations, Coding, Billing, HIM, Revenue Integrity, Compliance, and other stakeholders to resolve complex cases, clarify regulatory or payer requirements, and address recurring documentation or coverage concerns.

Maintain accurate records of cases reviewed, identified deficiencies, provider outreach, determinations, outcomes, turnaround times, corrective actions, and recurring areas of risk.

Analyze and summarize review findings, documentation trends, audit risks, and workflow outcomes.

Monitor changes in Medicare regulations, payer policies, NCDs, LCDs, and applicable coding or documentation requirements. Incorporate relevant changes into review criteria, workflows, and reference materials.

Develop and maintain vascular-specific and other assigned clinical reference materials, documentation guidance, educational resources, and standardized workflows.

• The ability to interpret and analyze medical record documentation, encounter forms, and lab reports, Explanation of Benefits, CMS claim forms, third party payor guidelines and government regulations.
• Aptitude for medical terminology, ICD-10, CPT-4, and HCPCS coding systems.
• Knowledge of research steps utilized to identify appropriate code selection or billing requirements.
• Working knowledge of CPT-based coding principles from both an inpatient and outpatient reimbursement perspective, UB-04, MA claim form, and the HCFA-1500, charging processes and compliance issues.
• Ability to prioritize and organize workload and meet deadlines.
• Proficiency in MS Office’s suite of products, including Access and PowerPoint, and the internet.
• Experience with Epic Billing and 3M Coding Systems.

RHIA, RHIT, CCS-P, CCS, CPS, or CPC
:
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Certified Professional Coder (CPC), or Certified Professional Services Coder (CPS); up to 10 years of directly related professional experience may be considered in lieu of the stated licenses/certification requirements.

Associates Required, Bachelors Preferred.

2 years experience in Revenue Cycle required