Charge Review Specialist

MIAMI VALLEY HOSPITAL

1 WYOMING ST, DAYTON, OH 45409

DEPT: CLINICAL RESEARCH CENTER

Full-Time / 8:00am - 5:00 pm

The Research Charge Review Specialist is responsible for reviewing and validating all charges for all subjects enrolled in clinical trials, for Premier Health based on Medicare Coverage rules and Clinical Trial contracts to ensure proper compliance and reimbursement. Engaged in proactive and independent line-item review of charge related items/encounters within Premier Health in collaboration with clinical research departments, while ensuring that performance metrics are at or above standardized levels.

The incumbent should be well versed in Medicare, Medicaid, and Research Billing policies. The Specialist serves as the expert Epic research charge resource for the Epic Research Module and acts as the conduit between all research coordinators, research administration, digital health and the specialty billers at Premier Health. Provides education on the intricacies of enrolling and managing subjects in Epic and the linkage of the research subjects to Epic.

Works closely with the Premier Health researchers and Patient Financial Services Department reviewing and applying Medicare Coverage Analysis and/or fee schedule; serves as expert resource for technical questions in budget negotiations with regard to clinical billing. Serves as the technical expert for complex research billing workflows, providing ongoing updates, and training to existing staff. Responsible for working account work queues, charge review edits, claim edits, etc. while ensuring the accuracy and completeness of all research-related charges within EPIC for accurate and timely billing.

The incumbent actively participates in internal audits, maintains documentation of current workflows, assists with special projects, and works closely with the Premier Health researchers, Internal Audit, Compliance, and Patient Financial Services Department. The incumbent assist with quality improvement initiatives to improve accounts receivable and improve accuracy and efficiency.

In addition, the Specialist is the primary contact responsible for answering questions regarding team functions, accurate and timely processing of study-related charges and responding to any concerns/appeals of various research coordinators and payers. Stays current on regulatory requirements and ensure regulatory changes are incorporated into process and workflow.

Responsibilities Include

Essential Duties & Functions:

• Reviewing charges daily that are in the Epic charge router review work queues, charge review work queues, and Epic generated reports to segregate them as standard-of-care services, research-related services, or indeterminate services
• Following federal and state regulations to ensure compliance standards are met
• Ensure that professional fees are adjusted the same way that technical fees are adjusted
• Verify payor source information and update registration as required
• Refer to study documents, study protocol, informed consent form, Clinical Trial Agreement (CTA) budget, and other resources to review new research patient accounts for patient care charges associated with each clinical research project
• Identifies appropriate use of billing modifiers and other CMS requirements for billing research-related charges to federal and non-federal payors.
• Flagging Studies as Medicare Qualifying Clinical Trials.
• Works with Patient Financial Services on the remediation of charge errors discovered during Epic review
• Communicate with Revenue Cycle/Patient Financial Services teams, payors, and others to resolve account problems; participate in meetings as needed to address any potential payor concerns
• Collaborates with the clinical research department administrators and study coordinators in the development and implementation of educational activities related to charge capture improvement projects
• Identify encounters of missing charges and communicating to the appropriate partner.
• Processes charge related corrections, additions, and removals in Epic for both the hospital and physician billing to ensure organizational compliance with all state and federal regulations
• Involved in developing strategy for maximizing financial opportunities in the conduct of research through accurate and timely charge review
• Complete work on special projects, queries and reports as assigned
• Attends training classes, as determined by management
• Complete quality improvement and productivity activities
• Answer questions regarding team functions and assist with team direction
• Assist in training staff as needed
• Performs other duties as assigned
  
  

The above duties and responsibilities may be essential job functions subject to reasonable accommodations. All job requirements listed include the minimum knowledge, skills, and/or ability deemed necessary to perform the job proficiently. This job description is not to be constructed as an exhausted statement of duties, responsibilities, and requirements. Employees may be required to perform any other job-related instructions as requested by their supervisor, subject to reasonable accommodations.

Minimum Level of Education Required: Bachelor's degree

Experience

Minimum Level of Experience Required: 3 - 5 years of job related experience

Prior job title or occupational experience: Experience in a research environment and emphasis in research charge review and billing practices

Prior specific functional responsibilities: Strong experience in computer use including Microsoft Office, database design, EPIC, network applications. Billing Rules for Medical, Medicaid, Research Billing, Presentation skills required.

Preferred experience: Compliance Auditing

Knowledge/Skills

• Excellent interpersonal skills required
• Ability to work with diverse audiences
• Understanding of Medicare billing rules and functional knowledge of essential National Coverage Decisions and the new CMS Clinical Research Policy
• Knowledge of medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, 1500)
• Working knowledge of Epic and MS Office
• Working knowledge of hospital charge capture flow
• Advanced analytic ability
• Strong attention to detail and ability to adhere to policies and procedures
• Ability to react to frequent changes in duties and volume of work
• Self-starter with willingness to try new ideas; positive, can-do attitude
• Ability to work independently while sustaining large volume of work.