Job Summary and Responsibilities
The Program Manager Revenue Integrity offers subject-matter expertise within internal revenue cycle systems to ensure efficient and compliant research patient billing practices across the Service Area of responsibility. This position performs duties of high complexity, judgement, scope, and responsibility with a direct reporting structure to Research Administration and a matrix reporting relationship to the Service Area Revenue Integrity Director to ensure cross-functional integration of accountability across both departments. The Program Manager Revenue Integrity is responsible for the planning and implementation of functional area-based system applications, developing work teams, task delegation, development of policies and work instructions and transactional management of charge review procedures to ensure services are compliant with Federal, State, private payer and other applicable legal and regulatory requirements for research patients.
This position works within Research Administration with close collaboration with Revenue Integrity Leadership and key stakeholders to ensure alignment of the research patient billing process across the service area. Additional responsibilities include the ability to build synergistic partnerships with internal/external teams, development and execution of an on-going training program and advanced technical knowledge with various software systems to identify gaps and work towards integration to improve process automation.
Essential Functions:Collaboration: Establish collaborative working relationship with research revenue producing departments (Physician Investigators, Research Program Leaders), revenue integrity teams, Optum 360 personnel, information systems personnel, technical and clinical personnel to identify research chargeable activities, establish charge capture mechanisms, and to properly code (or add modifiers) research charges for timely and accurate recording of research claim related revenue consistent with research regulations, state and federal requirements. Make recommendations and take actions to improve structure, system or outcomes.
Education and Training: Development of training plan to educate all stakeholders, including research personnel and coders on necessary chart documentation of research related services to ensure clinical documentation validates research billable charges. Responsible for development of quarterly chart documentation review(s) plan and preparation of summary report findings to share with department leadership across divisions to improve revenue recovery.
Research Charge Management: Responsible for review and development of Research Fee Schedule for Executive Approval annually. Development of Research Charge Description Master (CDM) in collaboration with key stakeholders responsible for CDM management. Work includes ongoing additions and management of research protocol itemsand services necessary to ensure effective research charge capture in compliance with CMS regulations and other third-party payer policies. Examples include addition of investigational drugs and investigational devices with ongoing maintenance consistent with research protocol contractual periods of performance.
Research Revenue Cycle: Manage research patient charge revenue cycle beginning with management of Medicare Cost and Coverage Analysis Worksheet (MCCAW) personnel required to translate MCCAW into research patient billing grid to identify billable versus non-billable research charges. Integrate research revenue workflows and needs across preauthorization, registration, charge-capture, charge-review and adjudication teams to ensure compliant claim distribution. Oversee charge reconciliation procedures including research claim holds, movement of charges and quality control methods for release within established timelines. Review research claim denials and develop corrective action plan(s) related to any deficiencies noted concerning research charge capture effectiveness and system integration. Work includes development and oversight of ancillary service provider agreements and invoice methodologies.
Quality Assurance: Develops and implements research Quality Assurance/Quality Control methodologies into operational workflow. This includes evaluation and identification of root causes resulting in deficiencies or lack of revenue recognition. Translate findings into action to minimize revenue at risk while identifying research charge trends and audit needs to improve service and ensure regulatory compliance throughout research revenue cycle.
Leadership: Serve as primary point of contact for all matters related to research revenue integrity with decisional authority to develop and distribute policies, work instructions and procedures necessary for efficient, effective and compliant workflows. Works synergistically with internal/external departments involved in the research revenue cycle. Maintains personal professional growth and development through seminars, workshops and professional affiliations. Establishes goals and objective for direct reports and guides cross-functional teams on transactional processing needs.Provides employees access to resources needed to advance subject matter expertise with a synergistic approach to training and process improvement plans.
Technology: Identify automation opportunities across software systems such as Cerner EMR, Clinical Trial Management System, Lawson, and various other coding and billing software systems in use within the assigned Service Area. Determines data sources necessary to establish data report information to continually review and recognize clinical research revenue opportunities. Initiate revenue report generation methodologies and stakeholder distribution lists to share research revenue charge trends and research revenue volume.
Other duties as assigned: Performs other related duties as assigned in a professional manner.
This position includes oversight and direction of research staff. Responsibilities include time and attendance, staff training/development and performance management to establish productive, high quality research programs.
Job Requirements
Required
- Bachelor's degree or a combination ofeducation and/or additional job related experience may be substituted in lieu of the degree., upon hire and
- Three years of revenue cycle experience including billing, coding and charge capture and two years of supervisory/management experience., upon hire
Preferred
- Masters Degree
- Five years of revenue cycle leadershipa nd/or clinical trial billing experience.
- Certified Coding Associate, upon hire or
- Certified Coding Specialist, upon hire or
- Certified Professional Coder
