Revenue Integrity Specialist

WVU Medicine; Oregon; Hybrid; USD 65,000 - 95,000; Full time

Job summary

SYSTEM West Virginia University Health System in Oregon seeks a billing/revenue cycle professional to review charge edits and maximize reimbursement. You will coordinate with leadership to optimize Epic Revenue Guardian tooling and ensure compliance with payer policies.

The role requires 2+ years of billing experience; a high school diploma is required, with a bachelor's degree preferred. Excellent analytical, communication, and computer skills are essential.

Qualifications

• High School Diploma or equivalent required.
• 2+ years billing/revenue cycle experience preferred.
• Bachelor's degree in business or health IT preferred.

Responsibilities

• Manages payor and claim edits (CCI, OCE, MUE, LCD/NCD) to ensure compliant, timely edits.
• Tracks edited accounts, actions, and outcomes; reports trends to leadership.
• Monitors denials and follow-up activities related to billing edits.
• Assists departments on compliance with government regulations for claim edits.
• Collaborates with Revenue Cycle leadership and departments to optimize charge capture.
• Keeps knowledge of payer policies and regulations; communicates updates to leadership.
• Performs root-cause analyses to reduce high-volume edits and routing errors.

Skills

Medical terminology

ICD-10/CPT codes

Analytical skills

Excel

Communication skills

Computer literacy

Education

High School Diploma or equivalent

Bachelor's degree in healthcare related field / Health IT

Job description

This position will review charge review, claim, and denial edits to ensure compliance with CCI, OCE, MUE claim edits and LCD & NCD billing rules, while maximizing reimbursement. Works with Revenue Cycle leadership to ensure ongoing development, testing, implementation, maintenance and operational optimization of Epic's Revenue Guardian module and/or other related claim editing software. Monitors trends in billing edits to identify needs for retraining and optimization of the build of editing tools to minimize manual intervention and maximize compliance. Works through Revenue Cycle leadership to communicate training and optimization needs to clinical leadership, chargemaster committee, compliance, and related areas.

MINIMUM QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

1. High School Diploma or equivalent.

EXPERIENCE

1. Two (2) years of billing- revenue cycle experience.

PREFERRED QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

1. Bachelor's degree in business or other healthcare related field or Health Information Technology graduate.

CORE DUTIES AND RESPONSIBILITIES

1. Manages payor and claim CCI, OCE, MUE, LCD and NCD edits in a timely, accurate and compliant manner.
2. Tracks edited accounts, correspondence, actions, and outcomes as well as coordination of activities and follow-up for payor and claim edits. Reports trends to Revenue Cycle Leadership
3. Monitors, analyzes and reports on denials appeals and follow-up activities related to billing edits.
4. Provides assistance to departments regarding compliance with government regulations, when requested as it relates to claim edits.
5. Works with revenue cycle leadership, chargemaster committee, and clinical departments (when required) to ensure optimal charge capture for services provided.
6. Maintains up to date knowledge of payer policies and government regulations to ensure compliant and accurate billing processes. Communicates relevant information to revenue cycle leadership.
7. Performs root-cause analysis for high volume edits to reduce the incidence of non-billable charges. Works with technical Epic team to correct any technical error causing incorrect charge routing and clinical departments and/or HIM on missed charges.
8. Reports on the volume of claim edits to leadership with the goal of reducing the volume of edits occurring over time and to quickly identify any new claim errors that begin with updated policies.
9. Performs claims reviews ensuring that record documentation supports charges captured.
10. Provides support and assistance to Revenue cycle Leadership as needed.
11. Prioritizes work to effectively reduce volume and meet payer appeal deadlines

PHYSICAL REQUIREMENTS

1. Frequent walking, standing, stooping, kneeling, pushing, lifting, grasping, and feeling are necessary body movements utilized in performing duties through the work shift.
2. Must be able to sit for extended periods of time.
3. Must have reading and comprehension ability.

WORKING ENVIRONMENT

1. Exposed to high levels of stress and anxiety.
2. Experiences constant interruptions.

SKILLS AND ABILITIES

1. Must be capable of using computers effectively.
2. Knowledge of medical terminology, ICD-10, CPT & HCPCS codes.
3. Analytical, critical thinking and clear, concise communication skills are required to interact effectively with all levels of management
4. Must be capable of using copier/fax effectively.
5. Good analytical skills including the use of Microsoft Excel and reporting tools.
6. Good communication skills and professional demeanor required.
7. Understanding of payor clinical reimbursement policies and government regulations.
8. Understanding of ACP/MPFS payment structures and other third-party payment methodologies.

ADDITIONAL JOB DESCRIPTION

Scheduled Weekly Hours: 40

Shift: Exempt/Non-Exempt: United States of America (Non-Exempt)

Company: SYSTEM West Virginia University Health System

Cost Center: 544 SYSTEM Patient Financial Services