Senior Coding Compliance Specialist, ACO

POSITION SUMMARY

Under the direction of the Chief Compliance & Privacy Officer and the Director of Compliance & Audit, the ACO Compliance Specialist will coordinate and support compliance functions and activities in support of enabling Sound Long-Term Care Management Accountable Care Organization (SLTCM-ACO) providers to comply with all applicable billing and privacy compliance regulations.

The ACO Compliance Specialist is responsible for conducting retrospective compliance reviews of documentation supporting codes assigned by practitioners to ensure accuracy in billing and compliance with Federal, State, payer, and institutional requirements. The ACO Compliance Specialist serves as the compliance lead and works cooperatively with SLTCM-ACO leadership and clinical leadership at ACO sites. Through the review process, the ACO Compliance Specialist also identifies opportunities to improve coding practices and related business processes or issues needing further review, assessment, and follow-up. The ACO Compliance Specialist provides individual and group coding and documentation training and works collaboratively with the Compliance Department and ACO Leadership to develop coding and documentation training materials and establishment of training plans for the practitioners in partnership with SLTCM-ACO.

The ACO Compliance Specialist contributes to compliance program development by maintaining data for program reports, participating in the development and/or delivery of educational and outreach materials, and maintaining program records. The ACO Compliance Specialist will maintain current knowledge of applicable laws and regulations and may contribute to the unit’s risk assessments and risk mitigation strategies.

The ACO Compliance Specialist functions as part of a unit team to accomplish unit goals and works cooperatively with other compliance staff and entity staff as needed to resolve shared issues and concerns. In addition, he or she may participate in committees, workgroups, or process improvement projects as assigned.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Perform complex coding and documentation compliance reviews of SLTCM-ACO partners in the Nursing Facility, Post-Acute Care, and Telemedicine settings using applicable rules, regulations, and coding conventions for billing to determine the accuracy of coded and billed services, including APP services where applicable.
• Conduct special reviews based on risk assessment activities, external or government audits, or in response to an inquiry or identified potential concern. Assess data and formulate recommendations to mitigate or resolve identified issues.
• Obtain, organize, and format billing and other data captured through the review process. Prepare clear, concise written reports related to the special review findings for internal and external reporting purposes; calculate refunds using a variety of methods, including extrapolation.
• Perform follow-up reviews to determine the status of implemented recommendations, efficacy of coding and documentation education as well as compliance with regulatory guidelines and internal policies.
• Report and review audit findings with Chief Medical Officer, Value Based Care for SLTCM-ACO and the Chief Compliance & Privacy Officer on a regular basis to identify trends, issues, and potential risk areas. Inform management of issues or concerns identified with coding practices of faculty or coding staff.
• Serve as a knowledge resource for coding and documentation standards. Respond to billing and coding questions related to review findings from ACO Partners and staff.
  Maintain effective and collaborative relationships with providers, administrative and revenue support staff.
• Maintain awareness of healthcare billing processes implemented in the organization.
• Maintain awareness of current compliance issues and coding initiatives through self-study and participation in professional educational conferences. Maintain coding expertise in assigned areas.
• Support institutional compliance efforts by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting concerns, and adhering to applicable laws, regulations and institutional policies and procedures.
• Perform other duties, as assigned.

STANDARD JOB RESPONSIBILITIES

• Assist Director of Compliance & Audit with establishing a prospective audit plan for the ACO sites and providers.
• Assist the Coding Compliance Supervisor with an initial assessment of all sites/providers participating in the ACO.
• Work directly with ACO Leadership to ensure compliance for providers under the ACO umbrella.
• Be responsible for auditing records for providers in the ACO who provide the following types of services: SNF, NF, Behavioral Health, Wound Care, Infectious Disease, Annual Wellness Visits, Chronic Care Management visits, and Telemedicine.
• Create and provide education to site leadership and directly to providers around CPT coding and billing related to the ACO.
• Communicate directly with site leadership, ACO leadership, and ACO participating providers to answer questions related to audited encounters and CPT coding and billing for ACO services.
• Adhere to all company policies and procedures.
• Always represent Sound Physicians and SLTCM-ACO confidentially and professionally.
• Immediately report regulatory compliance issues, or concerns to the Chief Compliance & Privacy Officer.
• Maintain strict confidentiality of all information obtained from any source in accordance with privacy and disclosure laws and Sound Physicians and SLTCM-ACO policies.
• Consistently demonstrate integrity, initiative, and team-building support.

KNOWLEDGE/SKILLS/ABILITIES

• Extensive knowledge of 2023 E/M Documentation Guidelines ICD-10 CM, CPT and HCPCS coding principles and guidelines.
• Knowledge of federal and state regulations related to documentation, coding, and billing.
• Knowledge of CMS, Medicaid, and Medicare Advantage.
• Ability to evaluate current workflows and processes with a critical eye and develop proposals for improvement.
• Ability to interpret physicians’ documentation and identify/extract billable services from medical records.
• Successful experience working both independently and as a team.
• Demonstrated ability to establish positive and courteous working relationships, effectively manage competing priorities, apply critical thinking skills, and accurately complete highly detailed work.
• Ability to work within a complex environment and leverage resources to meet the needs of clients, customers, and coworkers.
• Demonstrated ability to communicate effectively orally and in writing with all levels of management and medical staff.
• Ability to understand and analyze system connections and impacts, both internal and external, for a large healthcare organization.
• Ability to utilize root-cause analysis to make process improvement decisions and implement change.
• Consistent exercise of discretion and judgment.
• Documented initiative to further one’s coding skills via coding-related continuing education, professional association participation, or other similar activities.
• Excellent oral and interpersonal communication skills, with the ability to convey a positive and professional image in person, and to interact effectively with diverse personalities and backgrounds.
• Must be highly organized, detail oriented, and able to manage multiple competing priorities with a high degree of speed and accuracy.
• Proficiency with Windows-based software and Microsoft Office Suite products in a network environment.

EDUCATION

• Bachelor’s degree in a health sciences discipline, business, or related field desired or equivalent experience.
• A current coding credential from AHIMA and/or AAPC.

EXPERIENCE

Minimum of five years' experience with Nursing Facility, Telemedicine, and Post-Acute Care billing, coding operations, and compliance.

SPECIAL JOB OR ENVIRONMENTAL CONDITIONS

• May require periodic travel to Sound Physicians’ locations

OTHER PHYSICAL AND/OR SPECIAL REQUIREMENTS ABOUT JOB

• None

This job description reflects the present requirements of the position. As duties and responsibilities change and develop, the job description will be reviewed and subject to amendment.