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Principal Compliance Investigator

1 month ago

Hamtramck, Michigan, United States Henry Ford Health System Full time
GENERAL SUMMARY:

Under the direction of the Compliance Audit Manager, the Principal Compliance Investigator will oversee compliance auditing and monitoring to assess and identify compliance risks with Federal and State regulatory and contractual requirements. The Principal Compliance Investigator is responsible for conducting compliance audits, reporting results, identifying risks, establishing compliance monitoring processes, and assessing regulatory compliance of HFH operations.

PRINCIPLE DUTIES AND RESPONSIBILITIES:
  • Conducts internal investigations, including gathering and reviewing information, interviewing employees, preparing investigation reports, and identifying and aligning remedial measures/countermeasures.
  • Reviews and audits professional and facility coding and billing from all departments of HFH.
  • Conducts high-volume coding compliance audits across all HFH Hospitals in accordance with the Department Work Plan and other audits identified by Compliance Management; Reviews documentation and coding to ensure compliance with all Federal and State guidelines.
  • Reports on the accuracy of CPT, E&M, ICD-10-CM/PCS coding, and billing to ensure compliance with payer, legal and procedural policies.
  • Provides comprehensive guidance regarding proper coding and documentation practices consistent with HFH policies and best practices, and all coding, Federal and State regulatory, and reimbursement guidelines maintaining compliance.
  • Identifies inaccurate coding practices; prepares reports of findings and meets with providers and medical office staff to provide education and training on accurate coding practices and compliance risks.
  • Provides instruction to department staff and clinical employees in correct documentation processes and coding guidelines.
  • Provides instruction based on clinical documentation requirements related to regulatory and reimbursement rules and regulations, reimbursement systems (federal, state, and payer-specific), and health insurance processing.
  • Facilitates compliance-related data aggregation and the analysis of compliance related data, indicators, and initiatives to ensure the effectiveness of HFH's Compliance Program.
  • Validates the effective implementation of corrective action plans (CAPs) from internal departments & delegates to ensure appropriate completion and make necessary recommendations as needed for compliance.
  • Partner with and provide oversight and support to a variety of partners organizationally across HFH to conduct internal investigations. Provide guidance on internal investigation standard processes and oversight of appropriate and effective remediation where required to ensure compliance with regulatory expectations, law, the HFH Code of Conduct, and HFH policies.
  • Develop compliance communications and provide training and guidance regarding topics such as attorney-client privilege, investigative processes, company policies, etc.
  • Issue spot, conduct trend analysis, and assist with providing reporting and analytics related to internal investigations and other compliance data.
  • Help manage internal investigations program.
  • Assist with escalations and preparing reports and briefings to leadership regarding significant investigations.
  • Perform other compliance program-related duties as needed and assigned.
  • Ensure that all internal and external requirements are consistently met in an appropriate manner that allows HFH to serve patients and grow its business with a commitment to ethics and integrity.
  • Serves as a subject matter expert in compliance auditing, risk assessment, risk mitigation planning, and other compliance and regulatory-related matters.
Coaching:
  • Coaches and mentors team members and process owners at all levels of the organization.
  • Writes and reviews audit programs, audit work papers, and audit reports of other auditors based on audit results and ensures accuracy and quality of audit reporting.
  • Provide expertise and tools to managers, leaders, etc., to develop and sustain process improvements.
  • Can assess the culture and workplace environment using developing skills and competencies.
  • Ability to work effectively with departments and at all levels of the organization, including overseeing and directing the work of others.
  • Develops staff by assisting them to identify goals and opportunities for learning.
  • Guides other Compliance Team Members with data interpretation and implementation of Compliance initiatives.
EDUCATION/EXPERIENCE REQUIRED:
  • A two (2) year college degree required.
  • Minimum of 10 years in a managed care operation, working with one or more of the following areas: Utilization Management, Claims, Pharmacy Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals.
  • Demonstrated experience at a professional level, in an audit role, and in supporting compliance audit program initiatives.
  • Experience conducting compliance audits of a large multi-facility healthcare organization.
  • Demonstrates ability to think and work effectively under pressure and accurately prioritize and complete multiple assignments within established timeframes-five (5) years of experience in leading audits.
CERTIFICATIONS/LICENSURES REQUIRED:
  • American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) recognized certifications such as Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CPC-H), Certified Professional Coder-Payer (CPC-P), Certified Coding Specialist (CCS), Certified Coding Specialist - Physician Based (CCS- P), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or other specialty certification indicated by the department, plus 10 years coding, clinical, or billing experience. Additional certifications or licenses are a plus.
  • Certified Health Care Compliance (CHC) preferred but not required.