Under the general supervision of the Director of Billing Compliance, the Senior Compliance Auditor is primarily responsible for the execution of the yearly billing compliance work plan and participates in the yearly billing compliance clinician education. This position will be responsible for ensuring timely completion of billing compliance audits from the compliance audit team. This includes quality checks of the audits performed by other staff, development of audit reports, meeting with clinicians to review draft audit reports, as well as the finalization of reports, presenting information to departments upon request, and tracking completing audits and reporting to leadership when requested. The Senior Compliance Auditor is seen as a team leader and is expected to be very strong in both problem solving and conflict resolution/mediation.
ESSENTIAL RESPONSIBILITIES / DUTIES:
1. Responsible for conducting hospital billing compliance audits related to outpatient and inpatient claims, including CPT codes, ICD 10 codes and other codes related to hospital billing including revenue codes, modifiers and other hospital billing codes and related documentation.
1.1 Complete audits in accordance with established schedule accessing electronic and paper records.
1.2 Manage and maintain thorough results/findings. Assign performance scores based on results.
1.3 Manage and coordinate data results via Access database.
1.4 Report aggregate and specific findings to the Director of Compliance as requested including periodic reports.
2. Conduct and support educational interventions with clinical and administrative staff as needed related to error findings and corrective actions.
3. Assist in the implementation of billing compliance policies and procedures.
4. Prepare materials for educational sessions based on knowledge and familiarity with government rules on documentation, coding and billing.
5. Maintain awareness of directives of government agencies and legislation as they relate to coding and compliance activities.
6. Work with the Manager of Billing Compliance and/or Director of Billing Compliance and appropriate staff to review audit results.
7. Manage and maintain accurate information, including audit results and educational interventions, in compliance database.
8. Identify opportunities for improvement and recognize their relative significance in the overall system and provide recommendations regarding internal controls.
9. Work with a variety of hospital clinics to respond to requests related to documentation, coding and billing compliance questions.
10. Provide positive and effective customer service that supports departmental and hospital operations.
11. Develop and maintain professional skills and knowledge through attendance at relevant conferences, seminars and other educational programs, participation in professional organizations and review of current literature, consistent with Compliance Department program activities.
12. Maintain a professional level of communication through emails, phone calls and business letters.
13. Perform other related duties as required.
14. Must adhere to all of BMC’s RESPECT behavioral standards.
A combination of secondary education and compliance related job experience will be considered.
RN, other clinical degree or Master's Degree is desirable
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
Certification through the AAPC (CPC, etc.) and/or AHIMA (CCS, etc.) is required. Certification through HCCA is desired.
Minimum of 5 years of audit experience in a health care environment. Experience in compliance and/or revenue cycle/hospital billing is desirable.
Experience in giving presentations to providers is also desirable.
KNOWLEDGE AND SKILLS:
Candidate must be detail-oriented with excellent organizational and interpersonal skills. Candidate should have at least five years of experience reviewing hospital/physician documentation and assisting providers to meet government and other third party payer and CPT and ICD -10 coding requirements through individual and group training sessions. Work requires knowledge of healthcare compliance regulations. Focused experience in one or more medical specialties is a plus.
Work requires the analytical skills to collect information from diverse sources, apply professional principles in performing various analyses, and summarize the information and data in order to solve problems or design relatively complex systems and programs that cross department/divisional lines.
Work requires communication skills in order to effectively deal with conflicting views or issues and mediate fair solutions and well-developed writing skills.