The Revenue Integrity Specialist is responsible for the identification, implementation and monitoring results for all revenue integrity related activities in accordance with department policy.  This includes working with team members to identify causes of denied, rejected, or underpaid claims. The Specialist will take action in correcting errors and by making appropriate referrals that will result in the protection of potentially lost revenue.  The Specialist will track and report causes of denied, rejected, or underpaid claims.  The Specialist will work front end/ concurrent/ and retrospective cases for authorizations.  The Specialist will retrieve, enter and/or disseminate date to receive authorization on concurrent and retrospective case.  Provide information, through team reporting, to the appropriate persons in order to facilitate performance improvement throughout the DCH Health System.

1. Retrieve and disseminate clinical data to third party payers for authorization/certification of hospital level of care for front end/ concurrent and retrospective certifications
2. Refer adverse outcomes from third party payers to member of the utilization review team
3. Document certification data in Care Management and the Business Office systems. 
4. Identifies opportunities for improvement related to denial management and reports outcomes to Manager monthly.
5. Maintain accuracy of inpatient and outpatient working spreadsheet to include posting of payment, payment date, payer, and action performed.
6. Collaborates with the financial counselors /registration to identify correct payer source
7. Document data in third party payer systems allowable within the revenue integrity skillset
8. Document certification data in Care Management and the Business Office systems. 
9. Works within established processes of the UR to identify denied/rejected/underpaid claims.
10. Performs interventions, appeals, and appropriate referrals to protect and collect lost revenue.
11. Follows-up on inpatient and outpatient interventions and appeals to include calling insurance company, physician’s offices, patients, and related facility departments.
12. Assists manager in developing strategy for overturning appeals and denied claims.
13. Applies critical thinking skills and knowledge to each claim to prioritize and perform interventions in an effort to maximize revenue protection within timely filing.
14. Ensures communications are maintained with all involved departments.
15. Develops a detailed knowledge of the focus and goals of the Utilization Review (UR).
16. Supports the team through follow-up on Inpatient and Outpatient appeals and interventions.
17. Utilizing Compliance 360, Midas, eFR for reports and information related to denials. 
18. Attends division/departmental meetings.
19. Participates in an annual department project.
20. Arranges for Team meetings and is responsible for minutes as necessary.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

High School graduate or equivalent with some college preferred

Minimum of two (2) years of combined experience with registration, scheduling, insurance verification and patient collections preferred.

Strong organizational and computer skills are required.

Must have previous experience in working with multiple department heads and vice presidents in an effective manner and be able to do so in stressful situations.

Good telephone skills required.

Healthcare experience and knowledge of medical terminology required.

Ability to work, plan and coordinate registration and scheduling functions within one cohesive unit

Ability to develop and interpret computer-generated charts, graphs and reports.

WORKING CONDITIONS:

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.