1. Chargemaster

• Manage all chargemaster functions across the enterprise:

  • Develop and deploy chargemaster systems as part of TCHHN’s overall Revenue Cycle systems plan.
  • Monitor chargemaster systems and set TCHHN’s standards for data quality and ethical practice.
  • Provide guidance to charge-generating departments regarding strategic pricing services.
  • Oversee the resolution of specific billing edits/errors that require clinical expertise to ensure timely claim processing, effective AR management, and accurate reimbursement.
  • Serve as the principal point of contact for charging issues.
  • Manage CDM-related Epic projects including documentation, file building, testing, validation, workflow decisions, and implementation.
  • Ensure compliant revenue realization through revenue integrity program.
  • Create and monitor methods for charge reconciliation across clinical areas.
  • Oversee all charge review work queues.
  • Ensures the timely addition and deletion of new codes in the chargemaster. Work with process owners on code changes to ensure compliance.
  • Maintains exceptional chargemaster hygiene through audits, documented history of changes, and effectively communicate changes to stakeholders.
  • Create, update, and maintain all chargemaster processes and workflows.
  • Lead in the development of chargemaster policies and procedures related, but not limited to, revenue integrity and chargemaster.
    • Document compliance with and enforce Revenue Cycle’s policies and procedures.
    • Provide education and training to TCHHN employees in areas relevant to chargemaster policies and procedures.
    • Ensure education on accurate and compliant charging practices.
    • Monitor denial trends and conduct root cause analyses to identify denial improvement opportunities. Implement process improvements to reduce first pass and fatal denials. Track and report on the outcomes of interventions.
    • Support and facilitate clinical, administrative, and external data use functions.
    • Monitor local, national, and international trends in healthcare delivery.
    • Serve as an internal consultant on topics within span of control.
    • Plan and maintain a budget.
    • Establish relationships with vendor representatives to ensure the efficient operation of outsourcing company’s delivery commitments.
    • Ensure all TCHHN patients and families receive a world-class financial experience.
    • Coordinate up, down, across, and outside of TCHHN to ensure prompt, accurate, and compliant billing, charging, and collections practices.
    • Provide expertise in chargemaster practices to maintain the integrity of TCHHN operations.
    • Assist the TCHHN staff to ensure accurate documentation to support billing practices.
    • Work with selected vendors and TCHHN Information Technology (IT) in troubleshooting system problems and maintaining system capabilities.
    • Trend and analyze performance using data.
    • Monitor employee productivity and quality.
    • Direct and ensure appropriate chargemaster practices.
    • Create programs to ensure optimal billing, collections, and chargemaster to support reimbursement is achieved.
    • Ensure internal policies and procedures are maintained and updated as new services are implemented and regulations or requirements change.
    • Compare reimbursement profile with national and regional standards to identify variations requiring further investigation.
    • Monitor Medicare, AMA, and payer bulletins/manuals for pertinent changes to operations.
    • Review the current OIG Work plans for risk areas and create plans to mitigate.
    • Create and monitor dashboards and reports for in-scope units to identify patterns, trends, and variations in practices.
    • Evaluate the causes of changes or problems and take appropriate steps in collaboration with the stakeholders to effect resolution.
    • Communicate and work with Senior Leadership and Corporate Compliance to establish, maintain and provide leadership regarding post-service functions and reimbursement, and severity of illness.
  • Monitor charging functions to ensure accuracy and compliance.
    • Review claim denials and rejections pertaining to scope and, when necessary, implement processes, such as education programs, or modify current processes to prevent similar denials and rejections from recurring. Work with Payer Relations to escalate erroneous or questionable denials and rejections.
    • Monitor clinical documentation and charging practices for appropriateness of services provided to the patient. Ensure documentation is present to support accurate charging and billing.
      • Work with clinical staff to improve documentation.
      • Continuously evaluate the quality of clinical documentation to spot incomplete or inconsistent documentation that impacts the code selection and payment. Identify and implement solutions.

2. Manage the ongoing transition of technology platforms:

• Forecast TCHHN’s future technical needs to ensure compliance, prompt collections, and value for its customers.
• Partner with the Information Technology (IT) department to incorporate new technologies.
• Seek opportunities to translate the TCHHN strategic initiatives into an IT vision by keeping abreast of new technology to improve operations.
• Improve operations by developing processes that define leading practices for technical operational standards.
• Gain executive approval for IT investments.

3. Business Intelligence (BI)

• Guide performance from strategy through to frontline operations by giving the front-line information they need to know.
• Develop a BI model that is built around the needs of the organization.
• Design of a comprehensive program to lend support, analysis tools, and data necessary to make educated business decisions to hospital employees and management.
• Perform scientific and technical planning, direction, and analysis of selected BI systems used by management.
• Investigate existing national data and performing descriptive and analytic studies using statistical techniques.
• Provide ongoing data analysis to entity decision makers that are relevant to the healthcare market and assisting in problem solving, solution development, decision making, and strategic planning.

4. Unit Quality Initiatives

• Develop, implement, and maintain standardized policies and procedures which:
  • Monitor the success of chargemaster programs.
  • Review areas of risk.
  • Investigate identified issues.
  • Report data analyses.
  • Ensure compliance with external regulatory requirements.
  • Ensure consistency of quality data for the organization’s internal data needs.
  • Identify, investigate, and prevent violations.

5. Compliance leadership

• Establish, implement, and maintain a formalized review process for compliance, including an audit process.
  • Assess current compliance activities, identify areas of high risk, and evaluate risk factors in areas within scope.
• Oversee and monitor implementation of a charge integrity/chargemaster compliance program.
• Develop and coordinate educational and training programs on the results of auditing and monitoring activities to affected employees, providers, and leadership.
• Oversee internal investigations and review and act on reports of other potential problems.
• Approve corrective action to ensure resolution of problem areas identified during an internal investigation or auditing/monitoring activity.
• Report noncompliance issues detected through auditing and monitoring, the nature of corrective action plans implemented in response to identified problems, and results of follow-up audits to the corporate compliance officer.
• Receive and investigate reports of compliance violations and communicate this information to leadership and/or the corporate compliance officer.
• Approve disciplinary action for violation of the compliance program, the organization’s standards of conduct, or policies and procedures.
• Ensure the appropriate dissemination and communication of all regulation, policy, and guideline changes to affected personnel.
• Serve as a resource for department managers, staff, physicians, and leadership to obtain information or clarification on accurate and ethical billing, charging, and collection practices documentation standards, guidelines, and payer and regulatory requirements.
• Monitor adherence to the compliance program.
• Revise the compliance program in response to changing organizational needs or new or revised regulations, policies, and guidelines.
• Recommend revisions to the corporate compliance program to improve its effectiveness.