Description of the Job Class
Conduct health-system wide compliance audits to ensure
data integrity, compliance with federal and state regulations pertaining to but
not limited to: federal healthcare program requirements, coding, documentation
and billing. Interpretation of
applicable federal and state law & regulations to plan audit parameters,
determine department’s compliance with such regulations and communicate to
department necessary changes in compliance with regulatory requirements. As well as, manage health system wide
response to governmental audits to ensure data integrity and completeness of
records and accuracy of claims.
and Responsibilities of this Level:
- Responsible for conducting compliance audits, documenting
& communicating findings and recommendations, explaining regulatory requirements,
and overseeing the corrective actions for audits within DUHS
- Manage activities related to monitoring requests and
responses of governmental audits (e.g. RAC and Medicaid Program Integrity),
monitor and trend activity, and oversee and monitor appeals.
- Conduct risk assessments and preparation of work
- Develop an understanding of the operations, system
processes and procedures used in areas being audited.
- Review and test for compliance with institutional
policies and procedures, applicable laws and regulations through the inspection
of physical operations, processes, retrieval and review of documents and
investigation of irregularities and errors.
- Compile information and/or prepare reports and
analyses setting forth results of compliance audits with appropriate
recommendations; perform subsequent audits to ensure complete and appropriate
- Develop recommended corrective actions to address
- Actively participates in exit conferences, providing
clarification and supporting information necessary.
- Performs other related duties incidental to work
Qualifications at this Level:
degree in business administration, accounting, management, healthcare
administration, nursing or other related degree or experience equivalent to a
Experience with compliance auditing
- Experience independently
performing and conducting compliance audits including the review of
documentation, coding and billing.
· Experience in clinical research,
familiarity with protocols, clinical trials and clinical research studies is
· Experience with Federal auditing
process and regulations, including billing, coding and documentation
· Demonstrated experience
working as part of the interdisciplinary team.
Experience with EPIC is
- Research, abstracts and communicates Federal, State and payer
documentation, billing and coding rules and regulations; stays current
with Medicare and Medicaid rules and regulations, CPT, ICD, HCPCS, DRG and
APC coding updates related to clinical research and serves as a subject
Licensure, and/or Certification:
Coding certification (e.g. CPC, CCS, CHC, RHIA,
Skills, and Abilities:
Ability to be flexible, multitask,
and switch priorities as well as work comfortably in a deadline driven /
Ability to prioritize,
organize, plan, and implement services as well as handle multiple
Strong written and verbal
skills are required.
In depth knowledge of
federal regulations around clinical trials
EPIC and Microsoft Office experience preferred
Characteristics of this Level:
Required Qualifications at this Level
Work requires a general business background generally equivalent to a
Bachelor's degree in business administration, accounting, management,
healthcare administration, other related degrees.
Experience: 4 years of experience
related to legal, regulatory compliance, or a supervisory role in patient
financial services or HIM services.
Degrees, Licensure, and/or Certification:
Knowledge, Skills, and Abilities:
Knowledge of billing compliance, knowledge of
Medicare/Medicaid regulations, including billing, coding, and documentation
Coding certification (e.g. CPC, CCS, RHIA, RHIT) or
applicable experience is preferred.
In-depth knowledge of federal regulations
Strong oral and written communication skills.
of this Level