The Director of Revenue Cycle is responsible for all billing and collection and reporting of professional and medical services to ensure recovery of all inpatient and outpatient charges. Supervise the communications with insurance companies and patients in order to ensure prompt payment and disputes settlements. Supervise the coding and credentialing departments and work interdependently with the CBO Supervisor to ensure all claims are submitted without errors. Responsible for continual feedback to physician and satellite offices of all billing and coding issues. Monitors reimbursement to ensure contract payers are paying according to contract specifications.

Duties and Responsibilities:

• Develop, maintain, and monitor professional billing system by practice / program
• Implement and maintain systems to capture all inpatient and outpatient charges
• Maintain charge description master (CDM) by CPT code for each practice / program
• Identify and define appropriate CPT codes for existing and new services and programs
• Provide on-going training and education for staff on proper coding guidelines, insurance regulations, health records, physician documentation, and signature requirements
• Consult and advise with physicians regarding billing and coding concerns and implement plans for resolving such concerns
• Assist in evaluating and negotiating managed care contracts
• Review and manage the patient care accounts receivable (AR) and work with physicians and CBO staff to reduce outstanding claims and troubled accounts
• Responsible for analyzing unpaid and denied insurance claims to facilitate the processing of claims and receipt of payments from third-party payers
• Ensure secondary claims are accounted for and billed in a timely manner
• Data entry into a credentialing database of initial application or re-credentialing profile/application information; initial verification/re-verification information; licensure /certification renewal information
• Generate necessary correspondence (i.e. request for missing information letters, explanation of discrepancy letters, verification request letters, approval and continued participation / re-appointment letters
• Appropriately identify and forward applicant information to Medical Director or “credentialing committee” according to established organizational guidelines
• Coordinate credentialing committee meetings, as necessary, to assure committee members have necessary information, explain questionable information, and act as a resource for the credentialing process
• Monitors the data integrity of an applicant’s initial or re-credentialing information as it appears in the physician database in accordance with NCQA and/or JCAHO standards
• Conduct primary source verification of initial or re-credentialing files in accordance with BPHC and/or JCAHO standards
• Monitor licensure and/or certification expiration for physician; communicate physician non-compliance to Medical Director or credentialing committee.
• Manage physician sanctions and complaints through the Office of Inspector General (OIG), the Government Service Administration (GSA) excluded provider list.
• Performs other duties as requested.

Qualifications:

Bachelor’s degree in Business Administration or Accounting or equivalent is required or at least 5 years of equivalent work experience in Revenue Cycle Management.

Two years or more of healthcare billing, collecting, coding and credentialing or related experience and/or training; or equivalent combination of education and experience.

Certified Patient Account Manager (CPAM) or Certified Professional Coder (CPC) preferred.

Specialized Knowledge and Skills:

• Should be able to work independently and make intelligent decisions based on the information provided.

• Must be able to motivate team in order to ensure effective operation of office.

• Must be able to communicate effectively when in contact with physician offices, insurance carriers and patients.

• Must be able to maintain work production and meet various deadlines applicable to each assigned task despite numerous interruptions.

• Must have an in-depth knowledge of Medicare, Medicaid, Blue Shield and MCO contract payers.

• Must be able to use independent judgment daily and make decisions as appropriate.

• Should have the desire to work in a holistic health care environment serving the under insured and uninsured.

• Displays excellent reading and verbal and nonverbal skills, pleasant personality, visual, auditory and phonetic acuity required.