Revenue Integrity Manager

Description

The Revenue Integrity Manager is responsible for ensuring the integrity, accuracy, compliance, and optimization of the organization’s revenue cycle. This position serves as the bridge between clinical operations, compliance, billing, contracting, finance, and information systems to ensure services provided are appropriately documented, coded, authorized, billed, and reimbursed in accordance with federal, state, payer, and organizational requirements. The Revenue Integrity Manager proactively identifies revenue leakage, documentation deficiencies, coding opportunities, workflow inefficiencies, and compliance risks. This role develops and monitors key performance indicators, conducts audits, supports operational improvement initiatives, and partners with program leaders to improve financial and operational performance while maintaining high standards of compliance and client care.

ESSENTIAL FUNCTIONS:

1. Revenue Integrity and Revenue Optimization: Develop and maintain a comprehensive revenue integrity program across behavioral health, substance use disorder treatment, crisis services, residential treatment, withdrawal management, and medical services; identify, quantify, and reduce revenue leakage throughout the revenue cycle; monitor revenue cycle performance indicators and trends; analyze missed billing opportunities, write-offs, denials, underpayments, and documentation deficiencies; partner with clinical and operational leaders to improve revenue capture while maintaining regulatory compliance; and evaluate payer reimbursement methodologies and identify opportunities for optimization.

2. Documentation and Coding Compliance: Conduct routine documentation audits to ensure compliance with payer and regulatory requirements; review services for documentation completeness, medical necessity, timeliness, and billing readiness; monitor coding accuracy and consistency across programs; collaborate with providers and supervisors to improve documentation quality; and provide education regarding billing requirements, coding updates, and regulatory changes.

3. Authorization and Utilization Oversight: Monitor authorization utilization and service delivery against approved units; identify services at risk for denial due to authorization, eligibility, or documentation issues; collaborate with utilization review and clinical teams to maximize authorized service utilization; and monitor payer-specific requirements and communicate changes to operational leaders.

4. Denials and Payment Integrity: Analyze denial trends and root causes; develop corrective action plans to reduce denials and improve first-pass claim acceptance; partner with billing teams to resolve systemic denial issues; monitor underpayments and payer reimbursement accuracy; and support appeals and recovery efforts when appropriate.

5. Revenue Cycle Analytics: Develop and maintain dashboards and reports related to utilization, productivity, documentation timeliness, open encounters, authorization utilization, denials, clean claim rate, days in accounts receivable, and revenue leakage; present findings and recommendations to leadership teams; and support budgeting, forecasting, and financial planning efforts.

6. Cross-Functional Collaboration: Serve as a liaison between Clinical Operations, Revenue Cycle, Compliance, Quality, Information Technology, and Finance; lead revenue integrity workgroups and improvement initiatives; and support implementation of new services, billing rules, payer requirements, and workflows.

7. Regulatory Compliance: Maintain knowledge of Oregon Medicaid (OHP) requirements, Coordinated Care Organization (CCO) requirements, Medicare regulations, commercial payer policies, behavioral health billing regulations, and federal and state compliance requirements; support internal and external audits; and assist with corrective action planning and monitoring.

Requirements

EDUCATION AND/OR EXPERIENCE:

· Bachelor’s degree in Healthcare Administration, Finance, Business Administration, Public Health, Accounting, Nursing, Behavioral Health, or related field.

· Five (5) years of experience in healthcare revenue cycle, compliance, coding, clinical operations, or related field.

· Three (3) years of experience analyzing healthcare financial and operational data.

· Experience working with Medicaid and behavioral health reimbursement models.

LICENSES AND CERTIFICATIONS:

· Must maintain a valid Oregon Driver License or ability to obtain one upon hire, and be insurable under the organization’s auto liability coverage policy.

· Professional certification such as CHFP, CPC, CPMA, CRCR, or HFMA certification preferred.

PREFERRED:

· Master’s degree in Healthcare Administration, Business Administration, Public Health, Finance, or related field.

· Experience in community mental health, substance use disorder treatment, Federally Qualified Health Centers, or nonprofit healthcare organizations.

· Knowledge of Oregon Medicaid, Coordinated Care Organization reimbursement methodologies, and behavioral health directed payments.

· Experience with electronic health records, billing systems, and business intelligence tools.

REQUIRED COMPETENCIES: Must have demonstrated competency or ability to attain competency for each of the following within a reasonable period:

· Advanced understanding of healthcare revenue cycle operations.

· Knowledge of behavioral health documentation and billing requirements.

· Strong analytical, critical thinking, and problem-solving skills.

· Ability to translate complex financial and regulatory information into actionable recommendations.

· Strong project management and process improvement skills.

· Proficiency with Excel, reporting tools, data visualization platforms, MS Office 365, databases, virtual meeting platforms, internet, and ability to learn new or updated software.

· Excellent communication and presentation skills, including oral and written communication.

· Strong interpersonal and customer service skills.

· Strong organizational skills and attention to detail, accuracy, and follow-through.

· Excellent time management skills with a proven ability to meet deadlines.

· Ability to maintain strict confidence as required by HIPAA, 42 CFR, and Oregon statutes.

· Ability to build and maintain positive relationships.

· Ability to function well and use good judgment in a high-paced and at times stressful environment.

· Ability to manage conflict resolution and anger, fear, hostility, or violence of others appropriately and effectively.

· Ability to work effectively and respectfully in a diverse, multi-cultural environment.

· Ability to work independently as well as participate as a positive, collaborative team member.