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Sr. Compliance, Fraud Waste & Abuse Analyst Job in San Leandro, California

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Job Title: Sr. Compliance, Fraud Waste & Abuse Analyst

Employer:Community Health Center Network
Type:Full-Time
Skills:coding,billing,compliance,auditing,claims
Specialties:fraud waste & abuse, non-profit
Required Certifications:ICD-10,E/M Coding,HCPCS,CM/PCS,CPT-4
Preferred Certifications:HCPCS,E/M Coding,CPT-4,CM/PCS,ICD-10
Required Experience:1 to 2 years
Preferred Experience:3 to 4 years
Location:San Leandro, CA
Date Posted:1/14/2020

Organizational Description

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 services.

 

Position Title:             Senior Compliance and Fraud, Waste, and Abuse Analyst           

Department:              Compliance

Reports To:                Compliance Officer  

Classification:            Exempt              

Status:                        Full-Time Regular    

 

POSITION SUMMARY

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.

 

ESSENTIAL POSITION RESULTS

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 regulatory requirements/standards.

·         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.

·         Ability to ensure the confidentiality and protection of PHI and ePHI.

 

 

SUPERVISORY RESPONSIBILITIES

None  

 

MINIMUM QUALIFICATIONS

Competencies

  • Thorough demonstrated knowledge of medical terminology, ICD-9/ICD-10-CM coding, and CPT-4 coding.
  • Knowledge of insurance and coding guideline procedures
  • Knowledge 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 information.
  • Ability to prioritize multiple projects and maintain deadlines.
  • 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.

 

Essential Requirements

  • Experience developing a fraud, waste, and abuse audit program.
  • Must have a solid understanding of fraud, waste, and abuse processes for identifying highest risk.
  • Minimum 5 years of experience performing outpatient/inpatient coding

·         Knowledge of Community Health Center operations a plus  

  • 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

Applying

Kham Seng
Recruitment Manager
Office: 510-297-0405 
Email: kseng@chcnetwork.org
www.chcnetwork.org

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