Senior Compliance Audit Specialist

Job Requirements

Position Summary

The Corporate Integrity Senior Compliance Audit Specialist (SCAS), Evaluation and Management (E&M) services, serves in a consultative role to the organization for all aspects of provider coding, billing, and education. The position enhances provider documentation, coding and billing compliance through; auditing, monitoring and analysis of billing patterns, ongoing and routine audits and comprehensive, advisory and educational support. The position operates in partnership with clinical providers, medical directors, leadership, coders, and other internal and external customers. By providing

oversight and expertise in documentation, coding, billing and regulations, this position is integral to and directly influences the success of the organization's provider billing compliance and the organization's Corporate Integrity Department initiatives and annual work plan.

Minimum Requirements

Education

• High School Diploma or equivalent required

Experience

• Minimum 5-7 years coding/billing for provider medical services
• Exemplary written and oral communication skills; ability to navigate challenging conversations and provide effective provider education required
• Strong computer skills including proficiency with Microsoft Office products including Word, Excel, PowerPoint, and Outlook required
• Extensive knowledge and proficiency of CPT & ICD-10-CM guidelines required
• Self-directed and ability to work well both independently and with others

License/Registration/Certifications

• Certification from the American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC) or Certified Coding Specialist (CSS)
• CPC or CCS required

Preferred Requirements

Preferred Education

• Bachelor's degree

Preferred Experience

• 8-10 years' experience
• Experience with professional fees auditing, monitoring, and analysis including provider utilization, statistical risk assessment and report development preferred
• Experience with presenting and training of E&M guidelines and coding preferred
• Additional software experience with EPIC, E&M University, 3M Encoder and other coding related tools desirable

Preferred License/Registration/Certifications

• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) highly desirable

Core Job Responsibilities

• Works directly with the Privacy Officer and Compliance Director, VP Corporate Integrity, medical directors, the organization's leadership, and others to provide leadership, oversight and direction to ongoing activities related to E&M services
• Oversees, directs and monitors the development, implementation, and maintenance of the organization's E&M auditing and monitoring policies and procedures
• Serves as the organization's authoritative, content expert related to E&M services
• Reports and or presents compliance data, documentation, and other information, as requested, or needed, to the Privacy Officer and Compliance Director, the VP Corporate Integrity, executive leadership, or management as designated
• Develops and oversees the implementation of corrective action plans that result from auditing and monitoring activities, including the development of electronic templates to support documentation requirements
• Develops and implements E&M educational programs and tools for providers, resident physicians, coders, and others as appropriate
• Serves as advisors and educational support to the residency program through the development of educational programs for residents during their practice management elective and administers direct face-to-face didactic instruction including review of specific E&M scenarios
• Initiates, facilitates, and promotes activities to foster E&M compliance awareness within the organization and related entities
• Administers the process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the organization's E&M compliance and resolves customer concerns and complaints regarding specific E&M services and provides supporting information to providers, practices and patient financial services, as appropriate
• Maintains current knowledge of applicable federal and state laws, E&M guidelines and associated standards, and monitors changes and new developments to ensure organizational adaptation and compliance
• Monitors the OIG's work plan, CMS and other regulatory agencies and current industry standards relative to E&M focus audit activities
• Analyzes auditing and monitoring outcomes and develops initiatives and feedback for the annual Compliance Plan based on identified risks
• Monitors organizational, governmental, agency and other news and publications to stay informed and knowledgeable in E&M services, HCPCS, CPT and ICD-10, as appropriate
• Prepares scripts to electronically query specific data elements available from software applications to collect and analyze complex data of providers' coding, billing, and utilization patterns
• Develops methodologies to assess data elements to support E&M compliance for providers through analysis of billing and utilization patterns, performs routine, and focus audits and develops comprehensive educational sessions to improve performance based on the findings, as appropriate
• Develop risk assessment and management strategies that support the organization's compliance audit plan
• Collaborate with the organization to evaluate appropriate documentation, coding and billing and recommend, develop, or research tools and information to support these activities
• Provides evaluation and resolution, with authority, of complex reimbursement issues and inquiries originating from the professional billing staff, coding staff, patients, and other internal and external customers
• Act as content experts related to specific E&M matters through research, review and development of comprehensive education and training programs
• Provide periodic education and training with regard to National Correct Coding Initiatives and other industry recognized E&M coding standards
• Assist in the development, review and revisions of pertinent auditing and monitoring plans, action plans and education plans based on audit findings, audit outcomes, industry trends, government and other oversight notices and other internal and external factors, as appropriate
• Acts in a leadership role to Compliance Audit Specialists and others with regards to training, mentoring, directing, planning, and coordinating the auditing and monitoring of professional fees and services
• Act as a consultant to internal and external customers regarding provider documentation, coding, and billing, as appropriate
• Supports compliance and disseminates information to improve awareness and modify policies as needed
• Directs and or Attends compliance and related meetings as appropriate
• Assists in other matters, as directed
• Must be able to withstand stress and demands of an active position
• Must be able to withstand 6-7 hours of standing, walking, stooping, bending, and sitting.
• Manual dexterity, good eye/hand coordination and adequate vision and hearing needed in daily work
• Must be able to work in an active open work environment
• Must be able to read, write and speak English fluently
• Must be able to work as a team member with peers, other departments, staffs, and administration
•  Must have an ability to react effectively
• Must be able to set goals, organize, and prioritize work
• Must maintain a positive, professional appearance and attitude