Revenue Integrity Specialist

Position Title: Revenue Integrity Specialist

Location: Upland Hills Health - Dodgeville Hospital Campus

Role & Department: Revenue Integrity Specialist in the Revenue Cycle Department

Hours & Shift: Full-time (1.0 FTE) Day Shift Position, Monday through Friday

Position Summary: The Revenue Integrity Specialist serves as a bridge between billing operations, payor contract compliance, and reimbursement analysis. This role supports accurate and compliant charge capture, billing correctness while supporting denial prevention, revenue optimization, and team education. This role works closely with billing lead, contract specialist, and finance to protect and optimize organizational revenue.

• Responsible for assigned Pricing, Revenue Code, Account, Charge Review, Router Review and Claim Edit Work queues and the continual monitoring, reduction, and transfer of AR associated with the assigned areas.
• Monitors daily census of room rates for Med/Surg and OB floor.
• Follows up on all incomplete and inaccurate charges and makes prompt corrections.
• Responsible for the timely and accurate processing of patient and research charges and corrections to hospital account record as necessary.
• Works closely with Materials Management and Surgical staff to ensure appropriate charging and pricing for new supply products
• Applies analytical skills to daily work to identify trends or root causes and provides recommendations to improve processes across the revenue cycle (missing or delayed charges, lag time, claim denials, etc.)
• Creates temporary reports with findings of build issues to run on a daily basis until Epic tickets can be fixed.
• Coordinates with patient financial services on compliance issues regarding national correct coding initiative rules, Medicare outpatient code editor rules and Medicare and Medicaid fraud and abuse rules and charge practices.

• Estimate set up and workflow support.
• Maintains Revenue Integrity manual and workflows.
• Monitors quarterly WHA updates to Top 75 procedure list and forwards to Patient Access as required by regulations.
• Identify trends in billing errors, denials, and underpayments and recommend corrective actions.
• Assist the billing department with questions relating to revenue codes, modifiers, etc.
• Support revenue cycle improvement initiatives.
• Provides back-up support for State Reporting.
• Provides back-up support for the HB Statement processing and acceptance.
• Provides back-up support to the Revenue Integrity Analyst as it relates to Charge Capture Integrity.
• Additional duties as assigned.

• Analyze claim denials related to documentation, coding, billing or contract interpretation.
• Collaborate with billing lead and contract specialist to reduce payor-specific denial trends.
• Collaborate with registration, coding, clinical, authorization, and billing teams to improve claim accuracy.
• Assist with appeals by validating documentation, coding and contract language.
• Develop and implement corrective actions, including workflow changes, to prevent repeat denials.
• Maintain current knowledge of payor rules, medical policies, and contract requirements.
• Provide education and feedback to internal teams on payor-specific denial trends and prevention strategies.
• Prepare denial prevention reports, dashboards, and performance metrics.
• Act as a subject matter expert for denial prevention best practices.

• Bachelor’s Degree in Business, or related Medical Field, or equivalent combination of experience and education preferred.
• Required:
  
  Associate Degree in Business, or related Medical Field, or equivalent combination of experience and education.
• Knowledge of CPT and Medicare and Medicaid and other regulatory billing guidelines preferred.
• Experience with medical terminology, CPT coding systems preferred
• Ability to collaboratively coordinate, set priorities, operate with minimal direct supervision.
• Effective analytical ability in order to analyze, recommend solutions to and solve complex problems.
• Excellent interpersonal, organizational, and communication skills as well as the ability to problem solve
• Competency with Microsoft…