Under the direction of the Sr. Director or Sr. Manager, Revenue Optimization the Revenue Integrity Specialist is responsible for complete, accurate and timely processing of reimbursement/payment audits in compliance with Privia policies, payer contracts and government fee schedules. In addition, the Revenue Integrity Specialist is also responsible for addressing requests for Care Center payment performance audits to assist in maximizing cash flow, as well as, tracking and reporting the outcomes of both standard payer audits and requested Care Center audits. This position works collaboratively with our operations consultants, RCM AR staff and management.
Primary Job Duties:
- Auditing across all systems to ensure new provider and care center information is accurate
- Ensure reimbursement by payer is accurate per payer contract agreements, government and state rates by auditing payer processed claims
- Conduct Care Center audits following the audit policy based on the number of providers on a 30/60/90/120 post implementation/go-live date
- Assist the Sr. Manager, RI to lead initiatives that drive efficiency and partner internally and externally to deliver expected results (e.g; monthly market meetings with leadership, internal team meetings and meetings with top commercial payers)
- Make independent decisions regarding audit results, communicate with appropriate teams; contract negotiators, senior leaders, market leaders and/or directly with the payer to ensure optimal revenue opportunity
- Create, follow and ensure adherence to approved escalation processes to timely issue resolution and completion of action plans.
- Identify, monitor and manage denial management trends. Work closely with our Revenue Cycle Teams, payer representatives and create one pagers/reference tools on payer policies.
- Assist with Trizetto/Cognizant setup, fee schedule setup
- Work and address Salesforce cases along with athenaOne tables
- Perform other duties as assigned focused on key performance and department goals