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Compliance Auditor I

1 month ago

Palo Alto, California, United States Stanford Health Care Full time

If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered.

Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview
Compliance Hospital Billing Integrity Auditors conduct Compliance Department audits to determine organizational integrity of billing facility and technical hospital fees, including detection and correction of documentation, coding and billing errors and/or medical necessity of services billed. Audits consist of evaluation of the adequacy and accuracy of documentation in support of services billed, including ICD/CPT/HCPCS and other third party payor codes, DRG assignment, APC code assignment, medical necessity of services, reimbursement overpayments and underpayments, and compliance with other documentation, coding and billing standards.

Evaluate the adequacy and effectiveness of internal and operational controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and guidelines related to facility and technical fee documentation, coding and billing, including federal and state regulations and guidelines, CMS and other third party payor billing rules, and OIG compliance standards.

Apply standardized audit scoring methodology to consistently evaluate documentation and coding, and standardized audit findings methodology to report audit results. Compliance Hospital Billing Integrity Auditors communicate audit results to hospital service departments and departmental leadership, HIMS leadership, physicians, physician leadership, senior hospital management, coders, billers and other appropriate staff, provide physician and coder education and make recommendations for management corrective action.

Serve as institutional subject matter experts and authoritative resources on interpretation and application of documentation and coding rules and regulations, medical necessity of services delivered, and conduct enterprise risk assessments of potential and detected compliance deficiencies.

CAREER LADDER: Three (3) career banded levels are defined within this job family. Positions are flexibly staffed at any of the three levels and progression from one level to the next higher level depends, first, on the need for a position at the higher level; second on the nature, scope and complexity of the duties assigned; and third, on an employee's demonstrated and applied knowledge, skills and abilities and professional behaviors.

Compliance Auditor I is the entry, developmental and first working level of the Compliance Auditor Job Family. Work is limited to less complex audits. Non-routine problems/issues are referred to a higher level. Completed assignments are reviewed for conformance with standards, policies and procedures.

Locations
Stanford Health Care

What you will do

  • Contributes to the achievement of Compliance Department goals and objectives and adheres to departmental policies, procedures and standards; complies with governmental and accreditation regulations.
  • Effectively maintains collaborative working relationships with HIMS staff, PFS staff, hospital service department administrators, HIMS leadership, faculty, physician leadership, hospital management and staff to achieve increased satisfaction with and participation in the Compliance Program.
  • Performs scheduled and unscheduled independent Compliance Department audits of facility and technical fee documentation, coding and medical necessity related to inpatient and outpatient billing.
  • Conducts routine retrospective and prospective facility and technical fee audits, specialized and focused audits, and other audits as directed by the Hospital Billing Integrity Manager and Director.
  • Evaluates the appropriateness and medical necessity of services and procedures billed based on supporting documentation; evaluates appropriateness of ICD, HCPCS and CPT codes, evaluates the appropriateness of APC, DRG and admission assignments; evaluates appropriateness of modifier usage; makes determinations of overpayments and underpayments and performs other related analysis and evaluations.
  • Adheres to the defined audit timeline and audit protocol standards; assists with development of the audit schedule; identifies services to be audited.
  • Applies consistent and standardized compliance audit methodology for sample selection, scoring and benchmarking, development and reporting of findings and repayment calculations.
  • Prepares written reports of audit findings and recommendations and presents to HIMS staff, PFS staff, hospital service department administrators and management, physicians, coders, billing staff, and others as appropriate; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records.
  • Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities, ICD, APC and DRG utilization patterns, national normative data, CMS and PEPPER initiatives, OIG work plans and advisories, and healthcare industry best practices.
  • Researches, abstracts and communicates federal, state and payor documentation, billing and coding rules and regulations; stays current with Medicare, Medi-Cal and other third party rules and regulations, DRG, ICD, APC and CPT coding updates, Coding Clinic Guidelines; serves as institutional subject matter expert and authoritative resource in these areas.
  • Authors newsletter articles, FAQs, email alerts and other communication and educational materials; responds to informational inquiries from physicians, providers, coders, billers, management and staff regarding documentation, coding, billing and other related compliance matters.
  • Develops compliance training content; provides one-on-one and group training to HIMS staff, PFS staff hospital service department staff, physicians, clinicians, billing and coding staff, Compliance Department team members and others to ensure compliance with federal and state regulations and laws, CMS and other third party payor billing rules, and internal documentation, coding and billing policies and procedures; assists HIMS, PFS and other departments in evaluation of documentation, coding and billing processes and practices.
  • Assists in identifying areas of enterprise compliance risk and aids in resolution as needed; attends Compliance meetings as needed.
  • Assists departmental management with charge capture process and electronic medical record functionality and makes recommendations for improvement; assists departmental management with the development of documentation and coding tools and templates and makes documentation, coding and billing process improvement recommendations.
  • Assists Compliance Department management with federal, state and other special investigations and audits.
  • Participates in the development of the Compliance Department's long-term and short-term goals, objectives plans, policies and procedures; functions as audit team member and works on joint projects; maintains an effective working relationship with Compliance Department staff.
  • Annually identifies specific needs for self-development and implements a plan to achieve professional growth.
  • Maintains privacy of patient information and confidentiality of compliance information and activities; consistently demonstrates a high level of professionalism by exercising behaviors consistent with the Compliance Department's Guiding Principles, including but not limited to Integrity and Openness, Respect and Loyalty, Responsibility and Accountability, Balance and Control, Participation and Enthusiasm, and Humor and Fun.


Education Qualifications

  • High School Diploma or GED
  • Bachelor's degree in a healthcare-related field from an accredited college or university preferred


Experience Qualifications

  • 2 years of experience in facility fee auditing/coding or medical necessity reviews or related work.


Required Knowledge, Skills and Abilities

  • Knowledge of:
  • Medicare and Medi-Cal documentation and coding rules and guidelines or medical necessity defense reviews;
  • ICD/CPT/HCPCS/DRG/APC documentation and coding rules;
  • facility fee charge capture and reimbursement methodologies;
  • MS-DRG application; medical terminology;
  • healthcare compliance audit methodologies, principles and techniques;
  • CMS manuals, medical necessity guidelines, reimbursement and repayment principles, confidentiality standards.
  • Ability to:
  • interpret and apply documentation and coding rules and regulations, facility fee charge capture and reimbursement methodologies;
  • plan, organize and conduct healthcare compliance audits; work cooperatively with hospital administrators, service providers, and others;
  • work independently, exercise sound judgment, manage diverse and conflicting priorities and projects in an effective manner, and meet deadlines; conduct detailed compliance audits, reach independent decisions and logical conclusions, and prepare reports of findings;
  • maintain competence in and up-to-date knowledge of healthcare compliance requirements, practices and trends; interpret medical record progress notes, handwritten and electronic chart entries, provider orders and other related documentation; maintain confidentiality of compliance information and activities; proficiency in the use of personal computers with Windows operating systems, including the Microsoft Office applications such as MS Word, Excel, Outlook and PowerPoint; communicate effectively, both orally and in writing.


Licenses and Certifications

  • Preferred Qualifications: Current CCS or COC (formerly CPC-H) certification; Hospital Fee auditing experience in an Academic Medical Center; Experience navigating in electronic medical records; Certification in Healthcare Compliance (CHC) by the Healthcare Compliance Association (HCCA)

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family's perspective:

  • Know Me: Anticipate my needs and status to deliver effective care
  • Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
  • Coordinate for Me: Own the complexity of my care through coordination

#LI-RL1

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $ $54.66 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

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