WVU Medicine

• Conducts in-home, clinic-based, telephonic, and community-based wellness visits with patients/members as assigned. • Completes health risk assessments, social needs screenings, and follow-up activities to identify barriers related to health care access, food, housing, transportation, medication access, safety, utilities, and other social drivers of health. • Provides support, education, and reinforcement to help patients/members understand and follow their individualized care plans. • Supports medication adherence by providing reminders, identifying barriers to medication access or understanding, and escalating concerns to the appropriate clinical team member. • Assists patients/members with appointment reminders, follow-up care needs, preventive screenings, immunizations, routine checkups, and appropriate use of their medical home. • Facilitates transitions of care after hospital, emergency department, or skilled nursing facility discharge by assisting with outreach, follow-up needs, appointment coordination, resource connection, and escalation of concerns. • Connects patients/members to appropriate internal and external resources. • Helps patients/members access community-based resources, including food assistance, housing support, transportation resources, utility assistance, financial assistance programs, and other social service supports. • Assists patients/members with completion of forms, applications, resource referrals, and follow-up steps needed to access programs or benefits for which they may be eligible. • Serves as a trusted liaison between patients/members, families, community organizations, health care providers, clinics, and social service agencies. • Builds positive, supportive relationships with patients/members while promoting engagement, self-management, and active participation in health and wellness goals. • Documents all encounters, outreach attempts, assessments, identified needs, interventions, referrals, and follow-up activities in the appropriate electronic system according to departmental expectations. • Escalates concerns related to safety, unmet social needs, changes in health status, behavioral health concerns, medication concerns, suspected abuse/neglect, or barriers requiring clinical or social work intervention to the appropriate team member. • Maintains current knowledge of community resources, health care services, payer resources, internal programs, and referral pathways. • Works collaboratively and effectively within a team while also demonstrating the ability to work independently in community-based settings.

• Design and lead systemwide CDI, coding, UR, and denial management training using data-driven curriculum, competency assessments, and audit outcomes to improve accuracy, compliance, and preventable denials. • Provide focused training on DRG/CPT updates, clinical criteria, and payer policies; support onboarding of new providers and hospitals with standardized documentation and utilization expectations. • Offer individualized, case-based support to staff and providers, addressing real-time documentation, coding, medical necessity, and appeals questions. • Develop concise tip sheets, payer grids, documentation guides, and workflow references that reflect current CMS and payer standards. • Equip providers with clear guidance on admission criteria, medical necessity documentation, peer-to-peer expectations, and high-risk payer issues. • Monitor query accuracy, status determinations, DRG shifts, downgrades, and overturned denials; ensure findings drive corrective education. • Review internal/external audits to identify documentation, coding, or utilization gaps; deliver targeted education based on root causes. • Develop a coordinated, enterprise-wide education roadmap aligned with regulatory updates, audit trends, and CRC strategic priorities. • Collaborate with UR/CDI/Denials/RI leaders to interpret payer rules and create targeted training that reduces preventable denials. • Use insights from ClinIntell, CloudMed, Solventum, and Epic reports to focus education on high-impact conditions, DRGs, and denial patterns. • Gather frontline feedback, translate operational challenges into education updates, and ensure consistent cross-facility communication. • Develop cross-functional education modules that reinforce LOS optimization, DRG integrity, denial prevention, and Epic workflow standardization. • Provide expert guidance to directors, physicians, and executives on documentation integrity, medical necessity, and denial mitigation. • Track completion, competency, audit scores, and denial trends to evaluate program impact and refine future education priorities. • Deliver concise, data-driven summaries of progress, gaps, and recommendations to CRC leadership and CFO councils.

• Responsible for scheduling, cancelling, rescheduling and registering of outpatient visits and procedures for multiple ambulatory clinics. • Collecting all necessary information for schedule and registration preparation. • Obtain and verify patient guarantor information a minimum of once a year to ensure that the patient record is up-to-date. • Schedule and register patients/customers based on scheduling guidelines and medical appropriateness within the appropriate clinic. • Obtain and collect all necessary information from the patient/customer to schedule and register the patient for an appointment. • Identify and communicate need for scheduling modifications and development. • Notify appropriate personnel of any scheduling change due to patient cancellation in a timely fashion. • Receive and respond to patient and staff needs and complaints appropriately within the realm of the “patient care” environment, involving department supervisors and patient representatives as needed. • Consult with referring physician’s office to ensure written and/or electronic orders exist and obtain them as needed. • Verify upon receiving for completeness of the written orders and notes. • Make documentation that outside orders are requested. • Complete Workques as needed in a timely fashion along with daily tasks according to the scheduling area working in. • Respond to all patient communication in a timely manner. • Escalate any immediate needs to the appropriate area of responsibility.

• Responsible for posting insurance and/or patient payments to Epic and balancing those postings to the bank deposits in a timely and accurate manner • Assists Departmental Coordinator in researching and resolving outstanding deposits and unidentified or missing payments • Processes electronic remittances initiating transaction posting in Epic • Works transactions that do not post correctly to ensure that transactions route to the appropriate accounts • Identifies any unidentified payment transactions that route to the clearing account, following facility processes to move non-patient money to correct general ledger account • Balances postings to bank deposits utilizing provided technical tools in Epic and via Microsoft Excel • Maintains timely and accurate posting according to departmental goals and report to management • Documents accounts clearly and accurately • Analyzes and reconciles posting amounts from patient payment and other sources of payment (non-accounts receivable (AR) cash) to the patient accounting system and accounting department • Uses system software, including online credit card systems and the Epic system • Creates, enters, and assigns cash management batches • Opens and distributes mail received from the post office and financial institutions for the various entities services are billed for • Contacts the appropriate third party payors, business entities, or financial institutions to resolve unidentified or missing payments • Accesses any scanned information via One Content imaging system • Completes and reconciles bank deposits daily • Utilizes remittance work queues to resolve payment errors • Reviews and reconciles all postings monthly with the Departmental Coordinator as needed • Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth • Researches accounts in work queues with credit or undistributed self-pay balances, and works to resolve these balances by distributing to other outstanding account, refunding another approved facility, or refunding the guarantor • Investigates insurance overpayments and takes appropriate action from within the work queue to resolve the variance • Processes refund requests received from third party payors, clinical departments, other areas of Revenue Cycle, and leadership • Monitors accounts that fall within out special billing guidelines (i.e. cosmetic, bariatric, IVF, plastics, etc.) to insure pre-payment application is done within a timely manner • Works with the appropriate accountants to maintain a list of all unclaimed property, and maintain a spreadsheet for submission to the state • Takes calls from registration and customer service staff experiencing issues with cash drawers, and works to resolve the issues • Insures all refund requests are received from accounts payable, and processes the checks for submission to third party or guarantor • Maintains current knowledge of payor payment provisions and all local, state, and federal collection laws • Contacts insurance company or employer to determine eligibility, benefits, and payment information necessary to refund or distribute payments • Ability to accurately utilize payor portals to initiate overpayment recoveries • Identifies missing charges and communicates with appropriate coding manager for re-entry • Completes reports assigned by Revenue Cycle leadership for bulk refunds to third party payors • Monitors work queue for inappropriate hospital payments posted to professional billing, and works with appropriate entity for posting • Assists hospital cashier’s office in locating and resolving missing receipts • Aids accounting department in reconciling patient payments for the entity in which the receipt was deposited

• Analyze and resolve issues of missing charges and problem accounts. • Ensure appropriate reimbursement, compliance, and charging with the various coding guidelines and regulatory agencies. • Code a variety of patient classes including inpatient, observations, same day care, etc. • Perform the coding/billing Split Claims process. • Maintain and enhance current levels of coding knowledge through various means.

• Coordinate benefits with MA and Medicaid • Connect members to community resources • Participate in activities related to care management program • Ensure compliance with CMS SNP Model of Care expectations • Perform psychological, social and economic care management interventions • Assist in the development of individualized care plans • Document in the members’ case accurately and timely • Collaborate with the interdisciplinary care team • Maintain knowledge of community agencies and resources

• Provide pharmacist care by collaborating with multidisciplinary healthcare teams • Promote guidelines and policies to improve care for patients • Ensure patient compliance and minimize risk associated with high risk medications • Collect data and submit as required by various pay-for-performance initiatives

• Providing coordination of care to SNP members, including establishing and maintaining a care plan. • Coordinating care with ICT members and coordinating care during transitions of care. • Acting as a liaison for the Interdisciplinary Care Team (ICT) in conjunction with the PCP and beneficiary/caregiver. • Collaborating with other CM team members to support the beneficiary through TOC events. • Managing and triaging member self-referrals to care management programs. • Assisting in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.

• Act in coordination of the SNP Clinical team to provide ongoing coordination of care to members • Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations • Support members in guiding through Health Risk Assessment completion • Conduct timely follow-ups with members and/or their designated caregivers • Educate members on DSNP supplemental benefits and assist with access • Facilitate scheduling of PCP visits and preventive screenings • Document accurately to ensure coordination of members’ care needs

• Verify member information while addressing general questions. • Responds to and resolves all issues/inquires to assure an efficient and seamless member experience. • Maintains open channels of member communications doing outreach as required. • Meets all production and quality standards, maintaining work queues according to department standards. • Effectively communicates with internal and external staff. • Elevates issues to the next level of supervision, as appropriate.