The Community Health Center
Network (CHCN), sister organization to
the Alameda Health Consortium, is made up of the eight federally qualified
community health centers in Alameda County. CHCN functions as the managed
care MSO for our health centers, contracting with the Alameda Alliance for
Health and Anthem Blue Cross. In order
to help our health centers meet their missions of providing the best possible
care to their communities, we also provide a broad range of training, technical
assistance, quality improvement, information technology, and data analytic
Title: Senior Compliance and
Fraud, Waste, and Abuse Analyst
To: Compliance Officer
Status: Full-Time Regular
The Senior Compliance and Fraud, Waste, and Abuse (FWA)
Analyst is responsible for the implementation of FWA activities: investigations,
compliance audits, incorporating governmental and other agency regulations, Internal Compliance Program requirements, and other
operational policies and procedures.
The essential functions listed are typical examples of work
performed by positions in this job classification. They are not designed to
contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may
perform other duties as assigned.
Compliance & Auditing
Conduct focused medical record documentation and
coding/claims audits according to the Compliance Program requirements,
assessing the accuracy of ICD-10-CM/PCS, CPT, HCPCS codes, modifier
assignments, etc.; determining compliance with appropriate policies,
procedures, and Federal and state regulations; and identify procedural and
system weaknesses and offer guidance to Management for process improvements
Regularly review Medi-Cal Bulletins for new or
updated policies and benefits that may impact CHCN Claims operations.
Investigate compliance concerns and report
findings to Compliance Officer and Director of Operations
Monitor to identify patterns, trends, and variances related to auditing and
monitoring of coding projects and prepare the appropriate reports
Assist Provider Services, Compliance, and
Operations Departments to develop corrective actions as needed.
Conduct follow-up audits to appraise the adequacy
of corrective actions and determine whether deficiencies are corrected; prepare
the appropriate reports.
Perform provider audits offsite at CHCN clinics
in regards to E/M coding and ICD-10 as needed.
Review processed claims as identified by
Provider Services Department to ensure compliance with CHCN policies and
Conduct monthly Claims Department monitoring
activities and review findings with Claims Department staff.
Prepare monthly reports and present them to Compliance Officer and Claims Department.
Input, research and resolve and appeals received
from providers and vendors.
Make a sound
judgment on claim disputes that ensures compliance with CHCN policies,
government regulations and ICE standards, i.e. Ab1455, HIPAA, etc.
Review claims on hold for Coder review and
related documents for appropriate adjudication that focuses on proper use of
codes and applicable coding edits.
to ensure the confidentiality and protection of PHI and ePHI.
demonstrated knowledge of medical terminology, ICD-9/ICD-10-CM coding, and
- Knowledge of insurance and coding guideline
of physician office billing preferred
- Ability to accept and provide constructive feedback
- Ability to make decisions and take action based on high-level goals.
- Ability to learn, integrate and utilize new
- Ability to prioritize multiple projects and maintain
- Ability to utilize effective questioning and
listening skills in order to fully understand situations and processes.
- Excellent written and verbal communication skills, to
allow for effective communication at any level.
developing a fraud, waste, and abuse audit program.
have a solid understanding of fraud,
waste, and abuse processes for identifying highest
- Minimum 5 years of
experience performing outpatient/inpatient coding
Knowledge of Community Health Center operations
- Experience conducting
coding, documentation and coding/claims audits
- Participate regularly in
AAPC webinars and review for ICD and coding updates
CERTIFICATES AND/OR LICENSES
High School Diploma or equivalent
Certification in medical coding,
such as CMPA, CPC, or CPC-P required