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POSITION SUMMARY: Under the general direction and guidance of the VP, Revenue Cycle, the Senior Director is responsible for developing standards and ensuring the integrity of the integrated professional and facility revenue charge capture. This includes all aspects of the Charge Description Master and fee schedule formulary(s), review and maintenance to optimize revenue generation, and maintain compliance with third party payer requirements; charge entry and reconciliation; collaboration with all service lines across the BMC Enterprise; policies and procedures development, modification and maintenance. The Sr Director also is responsible for developing a charge audit/capture/reconciliation process and ensuring charges are maximized for reimbursement. The Sr Director also provides oversight and response for governmental audits such as RAC, MIC, and Third Party Payer audits. The Sr Director also participates in compliance related activities and denials root cause and process improvement, as appropriate. The Senior Director is the primary representative and face of the Physician Business Office (PBO) to the organization, Faculty Practice Foundation and external billing vendors. The incumbent will lead and manage complex revenue cycle projects - drive performance and provide overall direction and oversight of the functional areas (Physician Business Office, Revenue Operations/Business Intelligence, and Shared Revenue Systems/Cash Processing) that support the organization's financial and operational goals. They will develop policies, procedures, and workflows related to revenue cycle functions throughout the practices in collaboration with the operating Departments. Ensures compliance with CMS regulations, BMC policies, and standards for third party payors. Fosters and promotes a culture of excellence in customer service to internal and external clients. Builds trust and collaboration amongst the team by enhancing employee engagement, addressing performance results, and providing coaching and mentoring. Position: Senior Director Billing Vendor Management Department: Revenue Cycle Schedule: Full Time ESSENTIAL RESPONSIBILITIES / DUTIES: Leadership
Collaborate with the VP Revenue Cycle in defining vision, strategy and priority setting for areas of responsibility across the BMC System, including community hospitals. Work to standardize the processes and procedures throughout both the faculty practices as well as the facility. Conducts audits, on a periodic basis all areas treating patients to ensure all professional and facility billable charges are captured. This review is inclusive of, but not limited to, the departmental CDM and / or fee schedule encounter forms, systems generating charges (especially any mappings in an ancillary charge systems), reconciliation processes, revenue and usage reports, CPT / HCPCS codes, ICD-9 (ICD-10) codes and revenue codes. Direct, set vision, and define roles and responsibilities for the Department, including training, delegating tasks, overseeing daily activities, mentoring, guiding through demonstration of best practices and offering opportunities for professional development. Ensures the highest standards for the hiring selection, training, orientation and assignments of department staff. Provides leadership to direct reporting management staff with regards to the evaluation, promotion, resolution of employee relations/disciplinary concerns and the termination of employees. Develop and maintain methodologies to monitor departmental conformity to FPF and BMC standards related to charge posting, charge reconciliation and other billing related issues. Assess professional and facility charging and patient care documentation practices and procedures to ensure compliance with pertinent regulations and guidelines, and ensures efficient departmental operation by providing education and support. Facilitate the dissemination of information regarding coding and reimbursement to the appropriate FPF and BMC management and staff. Oversees communication of coding and reimbursement updates published in third-party payer newsletters / bulletins and provider manuals to all staff as appropriate. Provide communication and coordination with all departments regarding key charge capture functions. Oversee the management of the consolidated professional and hospital Charge Description Master (CDM), Fee Schedules, Charge Entry & Reconciliation efforts. The CDM / charges, charge entry screens, charge entry procedures, encounter forms and supply tickets are reviewed periodically with all departments, or as otherwise defined and / or needed. Serve as the FPF and BMC representative for charge capture and revenue integrity functions. Utilizes a proactive leadership style to model and promote a culture of trust and collaboration to provide vision and management expertise in guiding the complete process re-engineering of professional billing. Where appropriate, involves staff when recommended changes or actions may impact their work functions. Responsible for effective identification of staffing resources, recruitment, allocation of resources, retention, recommending salary changes and corrective action/ progressive discipline. Holds all staff members accountable for following to regulations, BMC policies, HIPAA laws, CMS guidelines and statutes. In collaboration with the Faculty Physician Foundation practices, manages vendor relationships while defining and developing accountability to leverage vendor performance; monitors vendor compliance with regulations, BMC policies, HIPAA laws, CMS guidelines and statutes. Functions as highly visible, approachable and accessible leader. Acts as catalyst to promote positive change, and stimulates others to do likewise. Creates a motivational environment. Provides challenging assignments and opportunities for development. Effectively communicates and disseminates information to staff. Encourages staff to attend educational opportunities relevant to their position and supports their attendance. Assesses and responds to current and future internal and external healthcare trends in order to establish and ensure the necessary direction for revenue cycle activities. Consistently and regularly reviews payor newsletters, updates from CMS or appropriate intermediaries, meetings and communications with payor representatives, and other sources and determines relevancy to the department/practices. Continually seeks opportunities for improving the delivery and support of the PBO revenue cycle activities and programs. Assures satisfaction among practices and other customer groups with the quality and amount of support provided by monitoring and responding appropriately to outcomes and feedback. Actively engages in understand the job functions of staff as it relates to process flow across the practices, and other departments, e.g., Patient Access Services, credentialing and enrollment, HIM, etc., as well as with billing vendors. Ensure adequate training and education occurs to both providers and hospital departmental staff regarding accurate charge selection / entry and documentation requirements. Analyze and influence appropriate action in all areas of reimbursement, by performing appropriate reviews, investigating trends and patterns and providing education regarding charge capture and charge reconciliation. Oversee data analysis, trending and management reporting to substantiate positive, compliant net revenue impact to FPF and BMC from the core functional areas. Oversee and manage payer relationships as related to defense audits. Ensure that controls are put in place to hold providers and hospital departments accountable for effectively managing charge capture and reconciliation processes. Develop controls and reporting processes related to audit issues, such as RAC audits.
Revenue Cycle Management
Oversees claims management, billing, accounts receivable management for the network of physician practices and practice sites. Understands EDI standards for electronic claims submission; demonstrated knowledge of third-party payer requirements for billing specialty practices (radiology, laboratory, surgical, split component billing, medicine specialties, etc.)
Understands and connects the roles and responsibilities of other key stakeholder departments and how they fit into the overall revenue cycle structure, including but not limited to:
Patient Access Services, Pre-Registration and Managed Care Departments Credentialing/enrollments department, and its support and adherence to NCQA standards for credentialing Centralized Call/Contact Center Revenue Integrity and Corporate Compliance
Ensures compliance with payer agreements as they relate to credentialing. Provides oversight to denial management and disputed claims processes and development of analyses to reduce controllable denials and related underpayments. Leads the management of accounts receivable to support monthly cash targets and overall revenue cycle goals. Analyzes the various methodologies for reimbursement and their contractual impact across the organization. Works with Finance and Accounting on issues between sub-ledger and G/L. In collaboration with Revenue Integrity, manages the charge master and pricing structure to ensure optimal reimbursement, operational efficiency and compliance.
Health Information Management
Technical Practice Management System
Oversee appropriate business applications in GE Centricity/IDX/IDX BAR/SDK/Epic systems, in collaboration with the BMC hospital and stakeholders. Actively participate in system upgrades and enhancements. Conform to hospital standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided. Utilize hospital's values and behavioral standards as the basis for decision making and to facilitate the hospital's goals mission.
OTHER DUTIES:
Serve as a resource for department managers, physicians and administration to obtain information and clarification on accurate and ethical billing standards, guidelines and regulatory requirements. Assist Patient Financial Services and FPF billing vendors with possible resolution and remediation efforts of billing edits due to charge issues, NCCI or OCE edits and medical necessity as necessary. Oversee research of billing and coding requirements when new procedures and / or supplies are introduced. If appropriate to bill for new services, ensures all billing systems are set up correctly, tested and monitors initial charging of services for proper billing as well as following claims for initial reimbursement. Monitor regulatory environment and implement appropriate workflow and process changes to support efficient, compliant and patient-friendly departmental outcomes and results. Oversees and communicates education and training with providers and department(s) as necessary, especially when changes are required for services charged within the department. Collaborate with administrative and clinical departments and Faculty Chiefs (as applicable) to identify opportunities to redesign processes and / or increase reliance on technology to improve revenue capture while complying with payer and regulatory guidelines. Develop and monitor metrics to ensure functions of the revenue integrity team are performed efficiently as well as with a high degree of customer service. Track, monitor and report trends of second level clinical appeals to Senior Management. This includes reporting on physician, service, and insurer.
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required). JOB REQUIREMENTS REQUIRED EDUCATION AND EXPERIENCE:
Bachelor's Degree in Finance, Financial Management, Finance Administration, Nursing or Information System Management, and a minimum of 10 years of experience in health care management, related field or equivalent experience in hospital revenue cycle operations.
PREFERRED EDUCATION AND EXPERIENCE:
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
CERTIFICATES, LICENSES, REGISTRATIONS PREFERRED:
Coding certification in at least one of the following: CPC, CPC-P, CPC-H or Certification in Auditing and / or Healthcare Compliance. Must obtain or be working towards certification within one year of hire.
KNOWLEDGE, SKILLS & ABILITIES (KSAs):
Knowledge of various hospital and professional fee coding systems including ICD-9/10-CM, CPT and HCPCS. Knowledge of the content, structure and maintenance of the Charge master and fee schedule. Knowledge in healthcare compliance, including privacy and security regulations, confidentiality laws, access and release of information Demonstrated leadership qualities and abilities with strong capabilities in change management Strong organizational skills with the ability to work on multiple, complex projects with high quality results Excellent verbal, written and attentive listening communication skills Strong collaborative skills to form working relationships with vendors, other departments, senior management, physicians and executives. Excellent analytical skills, including the ability to analyze quantitative and qualitative information and reach sound conclusions. Ability to perform A/R statistical analysis, identify gaps, develop and deploy solutions necessary for the achievement of key metrics (Days in A/R, aged receivable greater than 90 days, denial rate, bad debt percentage and collection rate.) Appreciation of timeliness with resolving issues and determining priorities. Strong planning and delegation skills, including ability to develop and cross-train staff. Possesses strong understanding of various reimbursement methodologies with expert knowledge of all payer billing requirements in both the facility and physician environments. Strong quantitative, analytic, and problem solving skills to evaluate all aspects of a problem or opportunity and draw valid conclusions to make or facilitate appropriate and timely decisions. Strong organizational skills to keep track of multiple priorities of highly detailed information. Proficient with standard Microsoft programs (i.e. MS Word, Excel, PowerPoint, Outlook) and web browsers. Advanced use of Micro Soft Excel and Access is preferred. Must be able to present information effectively in both written and oral forms.
Equal Opportunity Employer/Disabled/Veterans
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Boston Medical Center
Apr 17, 2025