Compliance Auditor - Pro Fee Remote
Job Summary: Under the direction of the Manager – Billing Compliance Audit Services, conducts coding and documentation audits of medical records to assess whether the documentation complies with applicable hospital and professional billing rules and regulations. Evaluates medical records to determine appropriateness of level of service, CPT/HCPCS, ICD-9, ICD-10 CM/PCS and revenue codes. Monitors enforcement activity and other indicators to assess risk of non-compliance for MH. Collaborates with leadership to ensure the execution of an effective compliance program, including training on coding and documentation rules. Upholds the mission, vision, values, and customer service standards.
Bachelor's Degree in Health Care Administration, Business or related field and experience in coding, billing, and/or reimbursement.
In lieu of degree, five to ten years of equivalent work experience will be accepted.
Certified AAPC (American Academy of Professional Coders) or AHIMA (American Health Information Management Association).
Proficient in Microsoft Office (Word, PowerPoint and/or Visio).
Advanced skills in Microsoft Excel.
Strong quantitative and analytical skills.
Excellent verbal and written communication skills.
Excellent presentation skills.
Additional certification such as CHC, CCS, etc.
Working knowledge of Epic.
Responsibilities:Contributes to patient safety by supporting the System-wide programs and policies addressing a safe environment for patients and the reporting of safety concerns to the appropriate individuals.
1. Assists the Manager – Billing Compliance Audit Services in the development of the annual Ethics and Compliance work plan. Contributes to the work plan by conducting analyses of high-risk billing and coding compliance areas.
2. Conducts prospective and retrospective audits in connection with the annual Ethics and Compliance work plan and emerging regulatory issues.
a. Audits include but are not limited to evaluation and management (E&M) services, documentation requirements, medical necessity of billed services.
b. Verifies the accuracy and completeness of ICD 10-CM, CPT-4, and HCPCs coding, including modifiers and/or units billed or other relevant variables.
c. Conducts follow-up audits according to the audit process.
d. Escalates non-compliance according to escalation procedure.
e. Documents and tracks audits within Ethics and Compliance database system.
3. Prepares written audit reports and makes recommendations for all noted deficiencies to appropriate stakeholders: billing provider, Coding Manager, HIM director, Revenue Cycle Director, and others as appropriate or requested (i.e., Department Chairs, Senior Leadership, etc.).
4. Maintains database of audit findings for tracking, trending and detecting of any compliance risks.
5. Assists with development of training material and information such as tip sheets derived from audit findings.
6. Provides education through a variety of modalities to providers, clinical, and coding staff based on audit findings. Develops materials and provides specialized training based on regulatory guidance and information derived from audit findings.
7. Assists in monitoring, investigating and responding to requests on compliance issues from regulatory bodies such as the Office of Inspector General (OIG), Department of Justice (DOJ), Centers for Medicare and Medicaid Services (CMS) or other entities.
8. Participates in internal investigations on reports of billing and coding non-compliance.
9. Performs in-depth research to address billing, coding, and documentation questions and maintains library of responses provided.
10. Serves as subject matter expert on standards for coding, medical record documentation, billing and reimbursement rules to advise providers and organization for professional and hospital-based services.
11. Coordinates external requests by Recovery Audit Contractors by:
a. Tracking receipt of requests for medical necessity denials
b. Reviewing pre-submission records to ensure completeness
c. Receiving denials and makes determination on appropriateness of appeal.
d. Coordinating first and second level appeals either independently or in conjunction with applicable departments
e. Coordinating remaining levels appeal including appeals to administrative law judge in conjunction with Manager – Billing Compliance Audit Services
f. Tracking and trending automatic takebacks to detect billing or coding concerns.
12. Works to ensure effective auditing and monitoring compliance activities by monitoring metrics and continuously seeking opportunities for improvements.
13. Works with the Revenue Cycle department on special projects such as denial reviews or high cost charge reviews, etc.
a. Evaluates trends for root cause
b. Works with Information Systems, Patient Financial Services, and coding staff to resolve identified issues
c. Facilitates implementation of resolution
d. Audits for effectiveness of plan
14. Assists in development of written departmental policies and procedures, auditing methodology, audit tools and guidelines.
15. Participates and contributes in collaboration meetings such as SPORC, Physicians' Coding Compliance, and Epical to address and correct any ongoing concerns and/or issues.