POSITION SUMMARY:
Serves as the hospital's principal authority and final decision-maker for the charge description master (CDM) and support software. Owns the strategic direction, governance, research, maintenance, and updates related to the CDM and Proration Plans. Partners directly with department directors/managers and hospital leadership to review and revise charges, direct the assignment of codes, design and improve charging procedures, and lead education efforts related to charging and the CDM. Holds primary accountability for ensuring the CDM and Proration Plans are in accordance with government compliance policies/procedures and commercial payer needs, and serves as the final escalation point for complex charge capture and coding issues. Performs medical record to bill audits as required. This is a non-union position.
ESSENTIAL JOB FUNCTIONS:
1. Leads the maintenance, strategic planning, and updates of the CDM, Proration Plans, and CDM maintenance software (Craneware), serving as the hospital's primary authority on charge master governance.
Directs and evaluates departmental requests to add or modify line items in the CDM, applying advanced judgment to resolve complex or ambiguous charge issues.
Ensures CPT, HCPCS, and Medi-Cal codes are updated and validated on a continuous basis, applying expert- level coding knowledge.
Oversees the ongoing configuration, maintenance, and optimization of Craneware, including advanced reporting and system enhancements.
Leads communication and collaboration with the CDM Committee, presenting recommendations and driving decisions regarding changes and updates to the CDM and Proration Plans.
Leads the annual review of unused/obsolete charges in the CDM, partnering with department managers to finalize deletions and mitigate revenue risk.
Ensures pricing consistency across duplicate items in the CDM, applying enterprise-wide pricing strategy.
Serves as the final reviewer for accuracy and completeness of charge descriptions and HCPCS/CPT coding; resolves escalated questions from managers/directors requiring clarification. H. Holds primary accountability for ensuring CDM and Proration Plans are in accordance with government compliance policies/procedures and commercial payer needs.
2. Directs the review and distribution process for all CDM and Proration Plan updates.
Leads distribution of CDM and/or Proration Plan information to department managers, ensuring timely understanding and implementation.
Develops and leads corrective action plans for CDM compliance issues, presenting findings and recommendations to the CDM Maintenance Committee for approval.
3. Serves as the primary partner to department managers on departmental charge changes, providing expert guidance and training.
Guides and mentor's department managers and staff in adding, changing, or deleting charges.
Serves as the hospital's lead resource for questions on charge appropriateness and HCPCS/CPT coding accuracy
4. Leads and performs complex medical record-to-bill audits, and serves as the primary point of contact for insurance company requests to perform on-site retrospective charge audits.
5. Monitors and analyzes new developments and regulatory changes in the health care industry affecting charging practices, HCPCS/CPT-4 coding accuracy, audit procedures, and compliance issues, and advises leadership on organizational impact.
6. Develops, writes, and maintains policies and procedures governing the CDM and charging protocols, and ensures organization-wide adherence.
7. Revenue Integrity and Charge Capture
Leads the hospital's Revenue Integrity Program to ensure accurate and compliant charge capture across all clinical departments.
Reviews charging workflows and identifies opportunities to improve revenue capture while maintaining regulatory compliance.
Partners with Revenue Cycle, Patient Financial Services, Health Information Management (HIM), Case Management, Clinical Operations, and Information Technology to improve charge accuracy and reduce revenue leakage
8. Regulatory Compliance
Maintains compliance with CMS, Medicare, Medicaid, Medi-Cal, Joint Commission, CDPH, OIG, and commercial payer billing requirements.
Monitors annual CMS Final Rules, OPPS, IPPS, MPFS, NCCI edits, and payer bulletins to ensure timely CDM updates.
Coordinates responses to external audits involving charge capture and billing compliance.
9. Pricing Strategy
Collaborates with Finance leadership to develop annual pricing strategies consistent with organizational financial objectives and market conditions.
Performs competitive pricing analysis using peer hospitals and benchmarking data.
Reviews departmental requests for new services and establishes appropriate pricing methodologies.
10. Revenue Integrity Audits
Performs proactive charge reconciliation between physician documentation, nursing documentation, ancillary systems, and patient billing.
Identifies missed charges, duplicate charges, and inaccurate charge assignments.
Develops corrective action plans and monitors implementation
11. Electronic Health Record (EHR) Management
Serves as the CDM subject matter expert for Oracle Health (Cerner) and other clinical information systems.
Participates in implementation, optimization, testing, and maintenance of charge-related workflows within the EHR.
Coordinates testing prior to system upgrades and application changes affecting charging.
12. Data Analytics
13. Committee Leadership
Co-chairs/Assists the Charge Description Master Committee.
Leads multidisciplinary meetings involving Finance, Clinical Services, HIM, Compliance, Revenue Cycle, Pharmacy, Laboratory, Imaging, Surgery, Emergency Department, and Information Technology.
14. Contract and Reimbursement Support
Assists Managed Care and Finance with reimbursement modeling.
Evaluates reimbursement implications of new procedures, technologies, implants, drugs, and service lines.
Supports cost report preparation by ensuring accurate charge structures.
Education:
Bachelor's degree in health information management, business, finance, or related field preferred. Strong training background in hospital coding and reimbursement required.
Experience:
Minimum of 5 years of progressive experience in CDM maintenance, medical records, hospital coding, or reimbursement required, including demonstrated experience leading CDM projects or initiatives with minimal oversight.
Advanced computer knowledge of Microsoft Word and Excel
Self-motivated, ability to work independently with minimal oversight and to mentor or guide less experienced staff.
Advanced communication and presentation skills, with the ability to influence and educate stakeholders across all levels of the organization, including senior leadership.
Licenses/Certificates:
