Description
• Serve as the clinical authority for revenue integrity across a multi-hospital academic health system, translating bedside expertise into financial stewardship that safeguards millions in earned revenue every year.
• Design, build, and continuously tune Epic Revenue Guardian edits that automatically flag missing, late, or clinically unsupported charges—turning complex regulatory rules into real-time safeguards that prevent revenue leakage before claims ever leave the door.
• Conduct daily, risk-based chart audits spanning inpatient units, ambulatory clinics, surgical suites, and ancillary departments; use clinical judgment to determine whether documented care matches charges, CPT/HCPCS codes, and payer policy, then quantify the financial impact of each finding.
• Partner with service-line leaders, physicians, and bedside staff to launch accurate charging protocols for cutting-edge therapies (e.g., CAR-T, robotic surgery, genomic testing) and high-dollar implants, ensuring that innovation is fully and compliantly reimbursed from day one.
• Translate dense Medicare regulations, NCDs, LCDs, and payer medical policies into concise, actionable education that nurses, residents, and APPs can apply at the point of documentation—reducing denials and improving patient accounting cycle time.
• Own a portfolio of KPIs: missing-charge dollars, charge-lag days, DNFB (Discharged Not Final Billed) aging, late-charge percentages, and clinically triggered charge accuracy; publish transparent dashboards that drive accountability across clinical and revenue-cycle teams.
• Lead root-cause analyses when denial patterns emerge—whether from coding gaps, charging misfires, or documentation insufficiencies—and orchestrate cross-functional workgroups (HIM, CDI, Case Management, Compliance, IT) to implement sustainable fixes.
• Leverage AI-driven analytics and robotic process automation to scan 100% of encounters for anomalies, prioritize the highest-risk accounts, and eliminate manual touches that slow cash acceleration.
• Serve as the clinical voice on the CDM (Charge Description Master) and Pricing Committees, validating that new charge codes, modifiers, and prices reflect actual resource consumption and comply with federal and state transparency rules.
• Mentor Revenue Integrity Charge Analysts, imparting clinical context that sharpens their audit accuracy and accelerates their professional growth.
• Test every new Epic build, upgrade, and bolt-on for revenue-cycle implications, writing user-acceptance scripts that ensure clinical workflows remain intuitive and compliant.
• Champion a culture of continuous improvement by facilitating monthly “lunch-and-learn” sessions, publishing quick-hit tip sheets, and rounding with high-volume specialties to celebrate wins and course-correct in real time.
• Maintain an expert-level understanding of CPT, HCPCS, ICD-10-CM/PCS guidelines, and CPT Assistant advice; serve as the go-to resource when coders or clinicians hit gray-area scenarios.
• Uphold the health system’s values of equity and inclusion by ensuring that documentation and charging practices do not inadvertently introduce disparities in care or reimbursement.
• Model professional nursing standards while operating in a remote-first environment—demonstrating self-direction, advanced communication skills, and disciplined use of secure technology to protect patient privacy and data integrity.