Job Summary:
The Compliance Auditor/Monitor has the primary responsibility of developing, implementing and conducting compliance reviews for both multi-specialty professional services and hospital services under the direction of the Manager of Compliance Auditing and Monitoring Services. All such reviews for both professional and hospital claims must be performed in accordance with requirements of Centers for Medicare and Medicaid (CMS) and the Compliance Audit Methodology. In this role, the Compliance Auditor will lead, provide expert technical skills, and assist with highly visible, sensitive, and multifaceted auditing and monitoring projects. He/She will evaluate compliant billing, documentation, and coding requirements, summarize findings, and propose recommendations for multi-specialty professional services and hospital claims. The Compliance Auditor will help determine if corrective action plans are needed to mitigate any risks identified in the audit. The Compliance Auditor will be responsible to prioritize audit projects, develop audit planning memorandums (e.g., audit methodology) audit programs, and prepare quality audit reports with limited revision. The Compliance Auditor will also be responsible for conducting and/or supporting investigative reviews when non-compliant activity is identified or suspected. This position will interact with all levels of management and employees, external consultants and/or attorneys. This position will be responsible for helping address billing compliance concerns reported to the Office of Compliance and Privacy Services.
The Compliance Auditor will be as assigned / prioritized to perform investigations or incident response, as needed, by the Manager of Compliance Auditing and Monitoring. The Compliance Auditor will also be responsible to provide education and training to Erlanger Health System providers and staff related to appropriate billing, coding, and documentation practices on an ad hoc basis or as needed based on the findings of the compliance auditing activities, regulatory changes, or other similar criteria. The Compliance Auditor must have expertise across multiple professional services lines as well as experience with reviewing hospital services for appropriate use of CPT, HCPCS, ICD-10, APC, MS-DRG, revenue codes, and other required coding to help ensure appropriate documentation, coding, and billing practices.
Education:
Required:
Degree in Nursing, Health Information Management, Health Information Technician or in other healthcare related field (i.e.). Bachelor Degree required within 1 year of employment. If candidate has extensive hospital coding and auditing experience and applicable coding certification, this may be considered in lieu of bachelor degree.
Preferred:
CPC-H, CPC, RN, LPN, RHIA or RHIT
Experience:
Required:
Three or more years of experience in evaluating and reporting on appropriate billing, coding, and documentation for hospital inpatient/outpatient claims.
Three or more years of experience in evaluating and reporting on appropriate billing, coding, and documentation for professional inpatient/outpatient claims across multiple specialties.
Must demonstrate knowledge of the Center for Medicare and Medicaid Services and other third party payor coding, billing, and documentation criteria.
Experienced in researching Federal, State & Payer coding and reimbursement guidelines and regulations and medical necessity criteria. Ability to compute ratios, percent, and to create and interpret graphs
Ability to define problems, collect data, establish facts and draw valid conclusions
Ability to effectively present information and respond to questions from supervisor and others
Ability to interpret variety of technical instructions or diagram form and deal with several abstract and concrete variables
Ability to use systematic approach to problem solving and troubleshooting
Strong project management skills, along with the ability to take initiative and work independently
High energy level, comfortable performing multifaceted projects in conjunction with day-to-day activities
Excellent interpersonal skills, ability to get along with diverse personalities
Demonstrates positive attitude, and able to interact well and collaborate with other corporate groups (such as Legal Department, Internal Audit, and Human Resources Department)
Able to work on several projects and investigations simultaneously.
Self-motivated; requires limited supervision
Ability to lead and perform special projects including using investigative technics
Ability to work on multiple projects and achieve deadlines
Detail orientated.
Proficiency in Microsoft Word, Excel, Access, Visio and PowerPoint
Preferred:
Five or more years of experience in a compliance auditing and monitoring role or leading a coding team with experience in reviewing hospital and professional inpatient and outpatient claims. Experience and exposure to healthcare compliance concepts and Medicare reimbursement principles. Experience reviewing hospital and professional claims to determine compliance with the requirements for billing services related to patients involved in research.
Knowledge and experience with various electronic health records. Knowledge of RAT-STATS Statically Valid Random Sampling methodology.
Position Requirement(s): License/Certification/Registration
Required:
At least one of the following certifications: Registered Nurse (RN), License Practical Nurse (LPN), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CPC-H), Certified Coding Specialist (CCS) certification.
Preferred:
Certified in Healthcare Compliance (CHC) and/or Certified in Healthcare Research Compliance (CHRC).
Prior knowledge and use of MDAudit
Department Position Summary:
The employee must be able to demonstrate the knowledge and skills necessary to audit the appropriateness of the coding, documentation, and billing of hospital and multi-specialty professional services outpatient/inpatient encounters. The individual must demonstrate knowledge of the various reimbursement guidelines for outpatient and inpatient encounters or the ability to research them and interpret them accurately. The individual must demonstrate the ability to be flexible as to the type of encounter to be reviewed. The associate must demonstrate the ability to work in a self-directed team by taking and providing coding guidance and sharing in the responsibility of the team. The associate must display the ability to be self-motivated, be able to evaluate the scope of each day's work, and display time management skills to accomplish the work evaluated. The associate must keep her/his licensure/certification current by participating in any required continuing education. The associate must provide management with appropriate documentation to demonstrate that any license or certification is current.
Perform compliance audits as per Compliance Audit Methodology including the following:
Assist / perform development & execution of claims data mining queries and analysis.
Perform Statistically Valid Random Sampling (SVRS) using the RAT STAT system when deemed appropriate.
Develop audit programs to meet scope and objectives as per Office of Compliance and Privacy Services annual work plan;
Research and apply appropriate Federal and State regulatory guidelines;
Research and apply appropriate EHS's coding, documentation, and billing guidelines required to perform specific audit.
Assist and/or perform review of audit results to determine the completeness and accuracy of work papers to support audit procedures performed and any outcomes or findings.,.
Identify and communicate with relevant EHS resources as required to perform audit;
Prepare draft audit report;
Ensure corrective actions recommended are timely, practical and relevant.
Perform other Compliance duties as assigned.
Performance Metrics:
1. Quantity = Perform assignments within budgeted resources allocated per project. Claims coding audit should be performed at an average of 2-3 claims / hour for inpatient claims. A 50 claim sample audit (Outpatient or Inpatient) should be completed within 1-2 weeks, depending on the audit complexity and criteria.
2. Quality = Perform assignments with proficiency and due professional care. Claims audit should be performed at a 98% accuracy.
3. Timeliness = Complete assignments within timelines and risk priorities defined.