Clinical Compliance Specialist

3 weeks ago

San Francisco, California, United States University of California , San Francisco Full time
Job Summary

This is a fully remote position. The Clinical Senior Compliance Analyst reports directly to the Associate Director of Revenue Cycle Compliance within the Office of Healthcare Compliance & Privacy (OHCP).

The Clinical Analyst serves as a centralized resource for planning, supporting, and conducting the claims appeal processes related to third-party payer and regulatory audits for UCSF Health hospital and professional revenue cycles.

The Clinical Analyst evaluates third-party payer and regulatory audit outcomes, proposes corrective actions for risk mitigation, and works with compliance leadership to ensure implementation.

The Clinical Analyst conducts coding and billing audits, including evaluation of medical necessity and/or compliance with clinical requirements related to reimbursement.

The Clinical Analyst applies extensive clinical knowledge to address regulatory audit findings and denials related to medical necessity and coding/billing, and serves as a clinical subject matter expert for the UCSF Healthcare Compliance Program.

Responsibilities
  • Conducts clinical and coding/billing audits to ensure compliance with regulatory requirements
  • Evaluates third-party payer and regulatory audit outcomes to identify areas for improvement
  • Develops and implements corrective actions to mitigate risk and ensure compliance
  • Collaborates with compliance leadership to ensure effective implementation of corrective actions
  • Applies clinical knowledge to address regulatory audit findings and denials related to medical necessity and coding/billing
  • Serves as a clinical subject matter expert for the UCSF Healthcare Compliance Program
Requirements

Bachelor's degree in healthcare or related field, and/or equivalent combination of experience/training in a hospital or large healthcare system

5 or more years of relevant work experience, including a minimum of 5 years progressive experience conducting clinical and/or coding and billing compliance audits for hospital and/or professional services

Clinical licensure (e.g., RN - Registered Nurse, NP, PA, MBBS)

Advanced knowledge of Medicare and Medicaid program rules and regulations and experience applying rules and regulations in order to defend medical necessity and coded and billed services in both hospital and professional settings

Strong knowledge and understanding of revenue cycle compliance and regulatory standards across the healthcare industry or in-depth knowledge within a specialty area

Ability to perform regulatory and industry research and apply complex clinical concepts relevant to clinical reimbursement requirements

Advanced organizational and project management skills, with the ability to collaborate with stakeholders, prioritize tasks, and see projects through from inception to completion on schedule

Advanced interpersonal skills for collaborating effectively with managers and staff at all levels and across the organization, and with payers as well as representatives of regulatory audit entities

Skills in coaching and mentoring peers

Advanced skills in written and verbal communications, with the ability to convey highly complex technical information, education, and instructions in a clear and concise manner, and to produce high-quality reports, documentation, presentations, and educational materials

In-depth ability to collaborate effectively with clinicians, senior staff, and management across departments, providing advice and counsel on complex regulatory issues of functionality, efficiency, and program development

Strong analytical and critical thinking skills, with the ability to quickly analyze problems, determine the appropriate level of intervention, and develop and apply effective solutions

Strong knowledge of medical records, medical terminology, principles of ICD-10-CM, ICD-10-PCS, and CPT coding

Strong knowledge of medical and surgical procedures and other healthcare practices and trends

Demonstrated ability to track/trend metrics related to appeal and denial processing

Preferred Qualifications

One or more of the following: RHIA, CCS, CCS-P, CPC, CDIP, CCDS

Experience with coding and billing audit software

Experience with Epic electronic health record system

Experience conducting defense audits and writing formal appeal letters

Experience in an academic and/or trauma level 1 medical center setting

About UCSF

The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging, and stem cells.

Pride Values

UCSF is a diverse community made of people with many skills and talents.

We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity, and excellence - also known as our PRIDE values.

In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce.

We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care.

Additional information about UCSF is available on our website.

Equal Employment Opportunity

The University of California San Francisco is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, or protected veteran status.

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