Compliance Examiner & Auditor - Integrity & Compliance Program - Full Time

Position Summary

A senior level Compliance Examiner and Analyst who works with the Compliance Officers to examine and analyze fraud, waste and abuse, compliance, and privacy related activities. Relies on professional judgement to ensure Internal Audit and Compliance standards are used to assess compliance with CPT, ICD-9/10, HCPCS, Payor guidelines, CMS guidelines, state and federal guidelines, cash controls, and TGC policies. Primary focus to analyze internal and external risks and develop a Work Plan to detect, audit, analyze and report, findings to Compliance officers and leadership partners. The position will also develop and provide guidance to improvement teams related to improving conditions that may have caused errors. Ability to work with high level management and physicians. Requires ability to present detailed analysis of audits in both written and spoken form.

Education, License, & Cert

•CPC (Certified Professional coder) required. LPN or CPMA preferred

•Will consider certifications from AHIMA (RHIA, RHIT, or CCS) or AAPC

•Minimum one-year experience in reimbursement and/or compliance field, or 5-year clinical management experience, or a bachelor's degree preferred

•(Certified Fraud Examiner a preferred certification?)

Experience

•Working knowledge of medical terminology, anatomy and physiology, and coding guidelines including CPT, ICD- 9 /10-CM, and HCPCS coding systems and guidelines, payer guidelines and requirements

•Demonstrated skills in measurement, analysis, and process improvement related to fraud, waste, and abuse environments.

•Demonstrated ability to provide written summaries of activities and guidance for improvement.

Essential Functions

•Conducts concurrent, prospective, and retrospective audits of medical record documentation, billing activity, provider activity, service lines, department processes, financials, contracts, assets, licensure/certification, etc., as applicable, for assessment of compliance with accepted guidelines (federal, state, local, and insurance regulations as well as The Guthrie Clinic policies, as applicable, Medicare, Medicaid, and LCD (Local Coverage Determinations), and NCD (National Coverage Determinations), insurance companies).

•Assists and coordinates with internal and external parties and performs compliance-related audits, including governmental audits (CERT and similar) and audit appeals, in conjunction with the IAC AVP, Chief Compliance Office & Compliance Officers to ensure compliance and privacy audits are completed and resolved in a timely manner.

•Communicates the results of compliance reviews/audits with all parties involved to ensure understanding of outcomes and any need for corrective actions.

•Research legislation, standards, and policies related to internal audit and compliance related topics and provides analysis to Compliance Officers or management as required.

•Research risk areas and compliance concerns related to coding and payer requirements and provides analysis to Compliance Officers or management as required.

•Develops Work Plan to address identified internal and external risks.

•Manages the Internal Audit and Compliance Work Plan including assignment, collection, analysis, reporting, and process improvement related to findings.

•Develops audit attributes and audit strategies with Compliance Officers to address areas of non-compliance detected in previous internal and external audits.

•Communicates findings with multiple levels of management including Sr. management as needed.

•Assists leadership with analyzing proposed new service lines and/or department process changes to identify compliance risks and develop audit activities to assess the risks identified.

•Reviews reports of documentation, coding, and billing non-compliance and assists in developing an appropriate corrective action plan if necessary.

•Coordinates with Compliance Officers to establish agenda, present findings and analysis to the Billing & Compliance Committee of the Guthrie Medical Group and other organizational committees.

•Communicates effectively with all levels of leadership, management, and professional provider staff.

•Requires the ability to take an unbiased approach to situations.

•Maintains excellent documentation of all reviews, methodologies employed, results, corrective actions implemented, and monitoring through departmental Work Plan.

•Gathers and maintains documents related to all investigative and analyst activities in a manner to assure ease of recovery for additional audits or investigations.

•Maintains professional and technical job knowledge by participating in educational opportunities, reading professional publications, establishing, and maintaining personal networks, and participating in professional organizations. Must maintain certifications once acquired.

•Creates and maintains KPI boards, IAC Work Plan(s), & applicable dashboards.

•Coordinates with reimbursement and insurance department to track audit financials, including charge corrections, self-disclosures, and claim denials.

•Assists Internal Systems Security Auditor with compliance related audits, analysis, and reporting to assure compliance with external standards of MIPS/MACRA and other value-based programs.

•Develops, provides, and maintains documentation of training for all levels of workforce related to Waste, Fraud, and Abuse and other compliance-related topics.

•Direct responsibility for assuring satisfactory completion of Work Plan items related to the Compliance Chart Auditor position.

•Coordinates meetings with internal and external auditors, payor audit teams, and internal and external legal counsel

•Presents audit findings to multi-level audiences.

Other Duties:

•Travel for this position is rarely required.

•It is understood that this description is not intended to be all-inclusive and that other duties may be assigned as necessary in the performance of this position.