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Compliance Auditor/Educator

2 months ago

Ann Arbor, United States Trinity Health Full time
POSITION DESCRIPTION:

The Revenue Site Operations Compliance Coding Auditor/Educator serves as the subject matter expert and as a point of contact for IHA offices and Revenue Department for proper coding procedures and workflow for existing medical services. Provides professional expertise and education in CPT, ICD and HCC coding. The Compliance Coding Auditor/Educator is responsible for professional development of educational materials, clinical case studies, guidelines and job aides to provide direction and guidance across IHA departments and offices for coding and documentation regulations. This role is also responsible for responding to compliance-related coding and documentation issues via the event reporting system and managing them to proper resolution. Performs medical record integrity audits and conducts one-on-one meetings with Providers for corrective educational guidance.

ESSENTIAL JOB FUNCTIONS:

  1. Develops and leads audit projects for medical record integrity, service line or issues-related audits, identifies problems and uses professional judgment and independent assessment.
  2. Reports audit results utilizing a standard reporting process. Performs thoughtful and multi-layered consideration of medical decision-making in relation to the nature of the presenting problem and clinical documentation.
  3. Identifies new errors while performing audits, investigates and assesses the root cause of errors and develops corrective action plans.
  4. Performs one-on-one Audit Meetings with Providers for corrective educational guidance; develops corrective action plans and related educational materials.
  5. Assists in the planning, organizing and completion of auditing activities required to comply with federal payers and other compliance-related requirements.
  6. Researches federal, payer coding and documentation requirements and develops comprehensive written processes and guidelines for correct coding tailored to specific situations and encounters. Performs critical analysis to apply complex coding rules to specific work processes and develops thoughtful, multi-layered recommendations and adjustments to office and department work flows to better comply with the standards.
  7. Monitors audit trends to identify errors in coding and documentation, lost revenue opportunities and any overpayments made due to errors in coding, insufficient medical record documentation and reports findings. Recommends process improvement strategies to IHA offices and departments. Monitors to completion.
  8. Educates Providers on correct coding principles and works with Providers to increase and strengthen health care providers' awareness and understanding of medical record documentation guidelines and coding principles.
  9. Serves as a subject matter expert in all areas of coding, documentation and audits. Acts as a key contact for Providers and Managers for auditing questions. Works as the liaison between multiple departments to provide guidance; serves as the subject matter expert and follows events to proper resolution.
  10. Provides training for IHA staff and providers on CPT, ICD 10 and HCC coding standards and procedures.
  11. Works closely with the Physician Coding Champions to develop and present effective coding education to Providers and Managers. Requests agenda time and presents corrective education based on audit findings to large Provider groups. Follows up on issues and implements actions plans.
  12. Develops job aids for all specific areas of specialty education needed. Addresses barriers to improvement while recommending action steps to improve performance.
  13. Develops coding articles for the monthly newsletter.
  14. Processes Queries via the Event System for all specialties.
  15. Rand guidelinesers on correct coding principles and esponds to event reports, reviews the problem and provides independent assessment and problem solving; develops corrective actions.
  16. Monitors billing event trends to analyze outliers and high trends; makes recommendations to resolve and promotes prevention steps.
  17. Collaborates with IHA's Compliance Team and Trinity Integrity and Compliance leaders to maintain coding standards and procedures in alignment with regulatory and payer requirements.
  18. Analyzes RBRVU data in correlation to IHA's fee schedule.
  19. Effectively navigates and analyzes systems and makes recommendations for change in Business System and Medical Record Systems, specifically with respect to proper billing, documentation and office procedures.
  20. Drives to offices and other training sites to educate staff and/or providers.
  21. Performs other duties as assigned.
ORGANIZATIONAL EXPECTATIONS:
  1. Creates a positive, professional, service-oriented work environment by supporting the mission and values of both IHA and Trinity Health.
  2. Must be able to work effectively as a member of the Compliance team.
  3. Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.
  4. Maintains knowledge of and complies with IHA standards, policies and procedures.
  5. Maintains general knowledge of IHA office services and in the use of all relevant office equipment, computer and manual systems.
  6. Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.
  7. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences.
  8. Uses resources efficiently.
  9. If applicable, responsible for ongoing professional development - maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.
MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

ESSENTIAL QUALIFICATIONS:

EDUCATION: Bachelor's Degree or equivalent combination of education and experience.

CREDENTIALS/LICENSURE: Certified Professional Coder (CPC) or RHIT with Professional coding experience required. Certified Auditor (CPMA), Certified in Healthcare Compliance (CHC) is desired or equivalent experience in Professional Coding and Compliance; HIM designation is preferred.

MINIMUM EXPERIENCE: 2 years of experience Professional coding, reimbursement analysis, insurance issue resolution and medical record auditing. Previous experience with primary care and multi-specialty care preferred and other relevant experience would include health care operations or process improvement work with a health care insurance organization. Health Information Management and data management experience is highly desirable.

POSITION REQUIREMENTS (ABILITIES & SKILLS):
  1. Ability to apply complex coding rules, numerous payer rules and standards.
  2. Demonstrated understanding and/or hands-on experience with office processes, procedures and workflows.
  3. Subject matter expert knowledge of managed care and insurance practices, insurance claims and billing process, fee schedules and pricing. Ability to research billing guidelines effectively to provide direction on compliance coding.
  4. Ability to serve as a role model for ethical management behavior, process improvement and promoting awareness and understanding of IHA's Standards of Care and Compliance Plan.
  5. Maintains substantial working knowledge of federal, state, and insurance company regulations and contract requirements affecting compliance in a healthcare setting; including compliance plan and auditing standards.
  6. Ability to independently review and apply high critical thinking skills, consider medical necessity of the presenting problem and analyze levels of medical decision-making.
  7. Ability to apply logic to assumptions and decision-making for areas that are not a black or white assumption.
  8. Proficiency in multi-tasking and meeting sensitive deadlines in a fast-paced environment with a personal commitment to producing the highest quality work and providing extraordinary customer service; demonstrated ability to effectively follow through on assigned projects.
  9. Possess excellent customer service and problem-solving abilities, collaborative and positive coaching skills.
  10. Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, Microsoft Word and Excel, PowerPoint, intranet and computer navigation. Ability to use other software as required while performing the essential functions of the job including EPM and EHR systems.
  11. Excellent professional communication skills in both written and verbal forms, such as via query, including proper phone etiquette.
  12. Ability to speak before groups of people, either in-person or virtually.
  13. Ability to create education materials, implement and present effective group educational sessions to providers.
  14. Ability to work collaboratively in a team-oriented environment; displays courteous, professional and friendly demeanor.
  15. Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, family members, insurance carriers, and vendors.
  16. Good organizational and time management skills to effectively juggle multiple priorities and time constraints in a fast-paced environment.
  17. Ability to exercise sound judgment and problem-solving skills.
  18. Ability to maintain any organizational information in a confidential manner.
  19. Successful completion of IHA competency-based program within introductory and training period.
  20. Ability to drive to offices and other training sites to educate staff and/or providers.
  21. Ability to work overtime hours as scheduled.