Key Areas

Key Responsibilities and Duties of the Job

Revenue Cycle Management Oversight

• Develop and implement strategies to optimize revenue cycle process, including claims adjudication, medical coding, and Medicare and Medicaid reimbursement.
• Oversee and manage a team of revenue cycle professionals, providing guidance, training, and support to ensure high performance and productivity.
• Support and develop reimbursement strategies and payment policies that benefit Immanuel while being reasonable to vendors.
• Analyze revenue cycle data, identify trends and opportunities for improvement, and implement solutions to enhance financial performance.
• Monitor key performance indicators and metrics related to revenue cycle operations and develop action plans to address any deficiencies or areas of concern.
• Establish and maintain effective communication channels with internal departments and external stakeholders to facilitate revenue cycle operations.
• Ensure compliance with regulatory requirements, industry standards, and organizational policies and procedures related to revenue cycle management.
• Collaborate with other departments, such as finance, accounting, and clinical operations to streamline processes, resolve issues, and optimize revenue capture.
• Stay informed about changes in healthcare regulations, reimbursement policies, rates updates, and industry trends that may affect revenue cycle process.
• Implement technology solutions and automation tools to streamline revenue cycle workflows, enhance accuracy, and improve efficiency.
• Prepare and present reports, analyses, and recommendations regarding revenue cycle performance, trends, and opportunities for improvement.

Risk Adjustment & Coding Compliance

• Lead risk adjustment initiatives, ensuring accurate coding, documentation, and submission of diagnosis code impacting Hierarchical Condition Category (HCC) scores and Risk Adjustment Factor (RAF) scores to optimize reimbursement.
• Collaborate with medical coder and providers to ensure coding guidelines and best practices for documentation improvement, coding specificity, and compliance are maintained.
• Monitor and analyze risk adjustment coding trends to identify opportunities for revenue.
• Oversee the performance of regular audits and retrospective reviews to validate coding accuracy, mitigate compliance risks, and optimize risk adjusted reimbursement.

Claims Management

• Provides oversight for all claims processing functions to ensure adherence for completeness and validity to determine payment/denials according to contracts, authorizations, and Medicare and Medicaid processing guidelines.
• Oversight of all contracted service payment rates (Medicare/Medicaid fee schedules) 
• Oversees the configuration of claims management systems and ensuring the correctness of said configurations; in addition to being a liaison between IT, PACE Centers, and contracted service providers.
• Oversees and troubleshoots all Encounter Data System (EDS) and RAPS transactions to submit accurate claims data to the Center for Medicare and Medicaid Services (CMS).

Data Management

• Collaborates with Director of Health Plan Management to develop fully informed views and insights into the drivers behind data, and present findings clearly and concisely.
• Monitors and analyzes data and quality review processes, evaluating results and recommending appropriate action/training.
• Prepare detailed reports for management and other departments by analyzing and interpreting data.

Revenue Cycle and Reporting

• Oversees all retroactive processing transactions to ensure timely Medicare payments and all actions have been successfully processed.
• Oversight of policies and methodologies from CMS and Medicaid State Plans that determine capitated payments to Immanuel Pathways.
• Works with the Revenue Cycle Specialist to identify, report, and resolve ongoing issues relating to accurate and timely claims payments.

Staff Management

• Provides leadership to direct reports including setting performance targets, monitoring performance, and providing development opportunities.
• Ensures workloads are balanced and that resources are being used effectively; adjust resources to meet business needs as necessary.

Other

• Assists with special project assignments.
• Performs other duties as assigned or requested.