Compliance Professional Auditor
· Conducts Department audits to determine organizational integrity of billing for professional services, including detection and correction of documentation, coding, and billing errors and/or medical necessity of services billed.
· Act as liaison with assigned faculty members, developing relationships and functioning as a resource to all providers and their staffs. Serve as an institutional subject matter expert and authoritative resource on interpretation and application of documentation and coding rules and regulations, medical necessity of services delivered, and conduct enterprise risk assessments of potential and detected compliance deficiencies.
The Ideal Candidate:
· Understanding of institutional risks and appropriate judgment to use a risk-based approach in planning and executing duties.
· Ability to interpret and apply documentation and coding rules and regulations and to interpret medical records progress notes, handwritten and electronic chart entries, provider orders and other related documentation.
· Ability to communicate complex and potentially sensitive issues to all levels of management including senior leadership. Exercises patience and consistency in approach and communications.
· Plans and performs scheduled and unscheduled compliance department audits, including accuracy and adequacy of documentation and coding related to inpatient and outpatient billing.
· Evaluates the appropriateness of services and procedures billed based on supporting documentation; evaluates appropriateness of ICD, HCPCS and CPT codes billed; evaluates adequacy of documentation to meet the Teaching Physician guidelines; evaluates level of service billed for evaluation and management (E/M) services, evaluates appropriateness of modifier usage; makes determinations of overpayments and underpayments and performs other related analysis and evaluations.
· Prepares written reports of audit findings and recommendations and present to appropriate stakeholders.
· Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities, coding utilization patterns, national normative data, CMS and CCI initiatives, OIG work plans and advisories and healthcare industry best practices.
· Develops and provides compliance training.
· Researches, abstracts and communicates federal, state and payor documentation, billing and coding rules and regulations; stays current with Medicare, Medicaid and other third party rules and regulations, CPT and ICD coding updates; services as institutional subject matter expert and authoritative resource in these areas.
Credentials and Qualifications:
· Bachelor's Degree – Health Information Management, Business or related field* *in lieu of Bachelor's degree, will consider candidates with HS/GED diploma and 7 years of additional related experience
· CPC or CCS-P, CHA or RHIA required, CHC preferred
· Three (3) years of experience in E/M and/or professional fee coding/auditing, medical necessity reviews or related work.
· Knowledge of Medicare and Medicaid documentation and coding rules and guidelines