Quality Improvement - Compliance Audit Specialist

Community Hospice & Palliative Care•Jacksonville, FL

About The Position

Under the direction of the Director of Quality, the Quality Improvement - Compliance Audit Specialist conducts medical record reviews and other audits to monitor compliance with internal policies and external regulations. The role also supports implementation of the Quality and Compliance Management Program, including development of policies, procedures, and compliance training. The specialist reviews records and audits, analyzes results, prepares reports with findings and recommendations, and works with agency staff to clarify clinical data and improve understanding of payer and regulatory documentation requirements. The position coordinates additional documentation requests and claim-denial appeals, tracks their progress, identifies potential denials, and supports appropriate reimbursement while maintaining compliance. The role investigates and responds to documentation, compliance, and reimbursement questions; analyzes related data; identifies educational needs; and helps develop and deliver compliance education. It also maintains knowledge of regulatory changes, participates in assigned committees and team rounding, and supports management with compliance projects and other duties as needed.

Requirements

Current licensure as a registered nurse in the state of Florida.
Three to five years of on-the-job experience in healthcare auditing, medical chart review, healthcare consulting, or with an insurance company or intermediary; clinical experience may also be considered.
Demonstrated proficiency with applicable laws and regulations, including Medicare, Medicaid, and other third-party payors.
Proficiency in reading medical records.
Excellent verbal and written communication skills.
Knowledge of general research methods, including research of healthcare regulatory requirements.
Ability to evaluate medical necessity using governmental regulatory and private payor guidelines and nursing judgment.
Demonstrated experience providing reports and presentations.
Ability to solve practical problems and exercise independent judgment when planning work details and making technical audit decisions.
Detail orientation, strong organizational skills, and ability to multitask and meet scheduled deadlines.
Ability to interact professionally with clinical and non-clinical agency staff.
Strong working knowledge of common business computer hardware and software, including Word, PowerPoint, Adobe, Excel, and the Internet.
Medical clearance for communicable diseases before direct patient contact.
Current immunizations, including but not limited to TB, Hepatitis, and Flu.

Nice To Haves

Previous hospice work experience is preferred.

Responsibilities

Assist with audit design and conduct medical record reviews and audits within established timeframes.
Analyze audit results and prepare formal reports with findings and recommendations.
Consult with agency staff to clarify clinical data and provide feedback on documentation and payer or regulatory requirements.
Process additional documentation requests from Medicare, Medicaid, and third-party payors, including record reviews, tracking logs, cover letters, and status reports.
Identify potential claim denials and work with organization staff to strengthen documentation where appropriate.
Assist with reviews of claims denied by Medicare, Medicaid, and third-party payors; document findings and prepare appeals when appropriate.
Coordinate denial appeals through final determination, maintain tracking mechanisms, and report on open denials and appeals.
Participate in developing and implementing improvements to systems and procedures related to claim denials.
Investigate, respond to, and communicate information about documentation, compliance, and reimbursement questions.
Compile and analyze data and advise management regarding documentation issues from a compliance perspective.
Develop and implement a system for documenting and communicating responses to compliance questions.
Identify and communicate educational needs based on clinical record and regulatory audits.
Assist in developing and providing staff compliance education, including education on clinical documentation and regulatory changes.
Provide current information and expertise on regulatory requirements and assist with compliance education materials.
Prepare reports and presentation graphics, maintain attendance lists, and log issues raised for future research and response.
Maintain knowledge of industry regulations, issues, and best practices, and communicate relevant changes to Compliance Department members.
Participate in assigned agency committees, attend meetings, and report on projects and findings as requested.
Participate in team rounding with patient care teams to solicit feedback and provide regulatory updates and education.
Assist management with special projects and perform other duties supporting the organization’s compliance program.