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Provides leadership  and  day-to-day operational management and direction for the  local hospital(s) and/or  Medical Group Provider Services (MGPS) revenue integrity functions.  Responsible for motivating staff to achieve the highest levels of performance, working in conjunction with all key stakeholders to prevent revenue leakage and maximize potential revenue for the region.  Manages Charge Description Master (CDM), pre-bill edits, root cause analysis, denials coordination with PBS, including complex case denials, denial prevention, audits, and education and training of multi-disciplinary hospital and/or MGPS teams.   Manages revenue optimization opportunities which may include charge control processes. Responsible for  optimizing staff and overall revenue performance through process redesign, policy/procedure implementation, communications, continuing education and professional development activities, staff empowerment and feedback.   

As a mission-driven innovative health organization, we will become the national leader in improving the health of our communities and each person we serve. By demonstrating reverence, commitment to those who are poor, justice, stewardship, and integrity, our organization will continue to provide better health, better care, at lower costs

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Works with Revenue Integrity and Payer Strategies leadership to ensure understanding of payer contracts, application of contract terms and ensures alignment with processes.

Monitors Medicare and Medicaid websites, as well as other -payer websites and newsletters for changes impacting charging, coding and billing.  Manages the process to apply updates and ensure compliance and revenue optimization.

Manages the coordination of denials received from Patient Business Service (PBS) center; ensures staff timely resolution and identification of denials' root cause.  Works with PBS and other Revenue Integrity leaders to create and participate in ongoing multi-disciplinary denial team.  

Manages and may perform the root cause analysis on denials and pre-bill edits and collaborates with inter and intra-departmental teams to implement process and/or identify system intersection opportunities to address cause and optimize revenue.

Prepares and conducts educational services to departments and staff pursuant to audit findings, regulatory changes and requirements, coding updates, and managed care billing requirement changes.

Manages the development of  colleague work schedules to ensure cost effective staffing that meets customer requirements and quality performance. Manages team projects, fosters interdisciplinary and intra department collaborative relationships, and promotes active participation.

Elicits feedback from interdisciplinary team, including the medical staff, and involves them in decision-making as appropriate.  Ensures problem resolution and corrective action for long-term solution, coordinating such effort across the intra and inter-departmental channels.

Formally assesses the developmental needs of the department on a periodic basis and promotes opportunities for development in independent decision-making, effective communications and interpersonal relations to ensure customer satisfaction in conjunction with Trinity Health’s core values and to foster team spirit.

Identifies and implements opportunities for colleagues to increase  knowledge base, advance  practice and enhance  professionalism through colleague orientation and continuing education opportunities May manage some degree of training to meet  goals.

Responsible for hiring employees and  allocation of resources based on scope of goals and priorities.   Monitors and conducts performance appraisals, including review and approval of performance goals, manages regular ongoing performance feedback and may terminate positions when necessary.

Provides feedback in a prompt, direct and positive manner; mentors and coaches  colleagues to ensure positive outcomes. Provides counseling and/or conflict resolution regarding unresolved performance issues, demonstrating effective use of the disciplinary process

Analyzes and displays data in meaningful formats; develops and communicates policies/procedures and other business documentation; manages and conducts special studies and prepares management reports, including Key Performance Indicators as they relate to the department.(

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity and Compliance Program and Code of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Other duties as assigned

QUALIFICATIONS

Must possess a comprehensive knowledge of Hospital and Physician practice operation, as normally acquired through the completion of Bachelor's degree in Finance, Business Administration or related field and a minimum of (five) 5 to (seven) 7 years of progressively responsible experience in revenue cycle operations, including revenue integrity, or equivalent combination of education and progressive revenue cycle experience.

Minimum of three (3) years of management  experience in a multi-facility, integrated health care delivery system or revenue cycle or revenue integrity consulting experience.

 Knowledge and experience in revenue integrity at an acute and/or physician practice.

Strong understanding of appeals, denial management, medical necessity, and coding audits with ability to read medical charts and dictation and correlate services to charges on the claim forms (UB and 1500).

Licensure/Certification:  RHIA, RHIT, CCS, CPC/COC or other coding credentials preferred  CDC (Healthcare Compliance Certification) preferred.  Experience in Charge Description Master (CDM) maintenance or oversight preferred.

Ability to organize, plan, and manage staff in Revenue Integrity and Optimization activities of a large healthcare acute and professional billing organization.

Knowledge of laws and payer contracts governing billing of hospital and/or physician services.

Demonstrated ability to work effectively with a diverse group of people including physicians, clinicians, office managers, administrators, third party payers, governmental agencies and  colleagues.

Ability to understand and interpret complex issues and clinical processes and recommend improvements.

Experienced with data collection, analysis, and providing written reports, proposals incorporating findings.

Ability to read medical charts and dictation, understand services performed and correlate those services to charges on the claim forms (UB and/or 1550 forms).

Strong knowledge of Diagnosis Related Group (DRG), Ambulatory Payment Classification (APC), and Outpatient Prospective Payment System (OPPS) reimbursement structures and prebill edits including Outpatient Coding Edits (OCE)/Correct Coding Initiative (CCI) edits and Discharged Not Final Billed (DNFB).

(Salary Range: $42.2592-63.3888)

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

This position operates in a typical office environment.  The area is well lit, temperature controlled and free from hazards. 

Incumbent communicates frequently, in person and over the phone, with people in all locations on product support issues. 

Manual dexterity is needed to operate a keyboard.  Hearing is needed for extensive telephone and in person communication. 

The environment in which the incumbent will work requires the ability to concentrate, meet deadlines, work on several projects at the same time and adapt to interruptions. 

Must be able to set and organize own work priorities and adapt to them as they change frequently.  Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. 

Ability to thrive in a fast-paced, multi-customer environment, with conflicting needs which some may find stressful.  May warrant varied and/or extended hours, with changes in workload and priorities to keep pace with the industry and advance strategic priorities.

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Our Commitment to Diversity and Inclusion 

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.