Revenue Integrity Manager, Central Audit-(3306802) - Partners Healthcare System

About Us

As a not-for-profit organization, Partners HealthCare is committed to supporting patient care, research, teaching, and service to the community by leading innovation across our system. Founded by Brigham and Women’s Hospital and Massachusetts General Hospital, Partners HealthCare supports a complete continuum of care including community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities. Several of our hospitals are teaching affiliates of Harvard Medical School, and our system is a national leader in biomedical research.

We’re focused on a people-first culture for our system’s patients and our professional family. That’s why we provide our employees with more ways to achieve their potential. Partners HealthCare is committed to aligning our employees’ personal aspirations with projects that match their capabilities and creating a culture that empowers our managers to become trusted mentors. We support each member of our team to own their personal development—and we recognize success at every step.

Our employees use the Partners HealthCare values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration

The Opportunity

Under general supervision of the Senior Manager of Central Audit, this manager will be responsible to develop and manage the performance of clinical audits to support the organization’s overall revenue integrity, manage the performance of third-party charge related audits and appeals, and participate in the development and implementation of best practice charge capture processes to support Mass General Brigham’s financial performance and ensure compliance with federal and state regulatory requirements in addition to payer/third-party reimbursement policies. This role will be responsible for the workflow development to record and respond to external/third-party audits, tracking appeal outcomes including the financial impact. It is recommended that the manager have experience with health care revenue cycle operations, and specifically in clinical and payer audits. The manager will be expected to interact often with various levels of team members throughout Mass General Brigham, as well as external parties such as payer staff and/or audit vendors.

Principal Duties and Responsibilities

• Uses the Mass General Brigham values to govern decisions, actions, and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration
  
• With RI leadership, will work to develop program vision as well as annual goals and objectives that are in alignment with Revenue Cycle Operations (RCO) team and enterprise vision, goals, and objectives.
  
• Actively oversees processes to ensure accurate recording of auditing, with dissemination to appropriate subject matter experts for review and appeal.
  
• Develops appropriate metrics of third-party payer audit volumes, appeal success rates, and financial impact.
  
• Ensures the documentation, and maintenance, of relevant department policies and procedures
  
• Assesses and recommends technical tools (i.e., audit manager software, BOT applications) to support work flows and analysis of audit impacts.
  
• Direct personnel management to include hiring evaluating performance and enacting corrective action if needed in line with Human Resource policies.
  
• Serves on enterprise and entity-based workgroups as required.
  
• Participates and presents at meetings as needed.
  
• Aware of all developments in the third-party audit field and continues to improve leadership and management skills through participation in professional activities, continuing education, and other related activities.
  
• Manages third-party payer audit requests and all related activities via a multidisciplinary team composed of Central Billing Office (CBO), Health Information Management (HIM), Home Care, Hospice, Revenue Integrity, Utilization Management (UM), and other ancillary service providers as appropriate.
  
• Utilizing audit manager software, manages third-party payer requests to track all response and appeal deadlines are met.
  
• Manage communications and hand-offs among departments participating in third-party payer audits to ensure all response deadlines are met.
  
• Develop a communication plan to share third-party payer audit activity during audit work groups, with at least bi-monthly frequency.
  
• Develop internal education and training based on audit results and/or industry identified trends.
  
• Provide third-party payer audit process and audit manager software training to new MGB users.
  
• Trouble shoot audit manager software user errors, participate in testing new functionality, and open enhancement requests.
  
• Act as a liaison between audit manager software and IS for 835/837 files and Event Messenger.
  
• Develop professional working relationships with payors and third-party auditors related to audit activity.
  
• Aware of government and commercial payor audit process changes and audit focus areas.
  
• Develop and modify third-party payor audit process workflows and training materials as needed.
  
• Assist with the preparation of monthly third-party payor audit activity and financial impact reports.
  
• Maintains active awareness of regulatory requirements to ensure MGB third-party payor audit activities are in compliance with local, state, and federal regulations as well as contracted agreements.
  
• Participates as a member of the Denials workgroup to aid in the overall reduction of denials by offering solutions and support to mitigate.
  
• Support, oversee, and manage clinical audit which focuses on identifying charge capture opportunities.
  
• Collaborate with IS and clinical departments to ensure optimal charge capture workflows and documentation is implemented and followed.
  
• Develop and report performance measures to RI leadership.
  
• Maintain up-to-date knowledge of regulatory and compliance changes impacting CDM, charging requirements and operations, and ensure team members and MGB staff are appropriately educated.
  
• Collaborate across cross-functional teams to ensure that the CDM, charging tools, processes, and documentation are modified as needed to capture appropriate revenue for services rendered.
  
• Review internal workflows to ensure optimal efficiency so that the team meets metrics and benchmarks as set by leadership.
  
• Assess direct reports’ performance on a consistent basis and provides feedback to reward effective performance and enable proactive coaching when applicable.
  
• Understands various clinical information systems and reviews both inpatient and outpatient accounts to ensure accurate and compliant charge capture practices.
  
• Collaborates with Revenue Cycle and clinical departments to provide education as it pertains to the principles of revenue integrity, including charge capture, denials, compliance, or chargemaster practices in accordance with local, national, and payer guidelines.
  
• Contributes and participates in management of departmental budget.
  
• Consistently provides service excellence to all patients, family members, visitors, volunteers, and co-workers.
  
• Ensures accurate collection of data for reporting purposes.
  
• Provides value analysis for operational reimbursement impact when charged are being considered and/or implemented.
  
• Develop, implement, and manage efficient and effective operational policies, procedures, processes, and performance monitoring across clinical audit processes and initiatives.
  
• Other duties as assigned

Education

• Bachelor's degree in healthcare administration, finance, or related healthcare administration program required or equivalent combination of education and experience.
• Master's degree in healthcare administration, finance, or related healthcare administration program preferred.
• Certification of at least one of the following preferred: CPC, CCS, CCP, CCA, RHIT, RHIA, CHRI, CRCR, or CRFP.

Experience

• 5 years of revenue cycle experience with a high concentration of audit experience required.
• 2 years of supervisory or management experience required.
• Experience and knowledge of regulatory, payer, and third-party reimbursement required.
• Experience and knowledge of both inpatient and outpatient hospital payment methodology required.
• Experience at an academic medical center, or in a multiple facility system preferred; combination of education and experience may be substituted for requirements.
• Epic experience strongly preferred.
• Proficient knowledge of CPT/HCPCS codes, revenue codes, cost centers, modifiers, etc.) required.
• Ability to work under pressure and manage multiple initiatives concurrently; must be able to work independently, set priorities, and meet deadlines.
• Excellent communication, leadership, delegation, and interpersonal skills required.

Skills/Abilities/Competencies

• Exceptional interpersonal skills to effectively communicate with cross-functional teams including staff at all levels of the organization.
• Ability to successfully negotiate and collaborate with others of different skill sets, backgrounds, and levels within and external to the organization.
  
• Exceptional problem solving and negotiation skills.
  
• Ability to effectively conduct meetings, both formal and informal.
  
• Requires minimal direction from leadership and possesses the ability to learn quickly.
  
• Highly organized, easily able to take initiative.
  
• Demonstrated experience with computer systems including EPIC.
  
• Extensive Microsoft office experience, especially Word, Excel, PowerPoint, and Outlook.
  
• Demonstrated ability with data management.
  
• Experience managing diverse teams, developing team member skills, and achieving shared goals.
  
• Ability to complete projects within presented timelines and deadlines.
  
• Strong analytical and critical thinking skills.
  
• Ability to work independently yet remain a team player.
  
• Ability to research complex coding and regulatory requirements.
  
• Ability and willingness to seek out and embrace change.

Working Conditions

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

• This position is Hybrid, M-F Eastern Hours Remote, with the expectation that leaders will be asked to come into the office, on average, once per quarter for up to 4 business days (travel will be reimbursed per MGB policy).
• Remote days require stable, secure, HIPPA compliant work station with ethernet connection and free of distraction

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.