Senior Compliance Audit Specialist

Spartanburg Regional Healthcare System•Spartanburg, SC

7d•Onsite

About The Position

The Corporate Integrity Senior Compliance Audit Specialist (SCAS), Evaluation and Management (E&M) services, serves in a consultative role to the organization for all aspects of provider coding, billing, and education. The position enhances provider documentation, coding and billing compliance through; auditing, monitoring and analysis of billing patterns, ongoing and routine audits and comprehensive, advisory and educational support. The position operates in partnership with clinical providers, medical directors, leadership, coders, and other internal and external customers. By providing oversight and expertise in documentation, coding, billing and regulations, this position is integral to and directly influences the success of the organization's provider billing compliance and the organization's Corporate Integrity Department initiatives and annual work plan.

Requirements

High School Diploma or equivalent required
Minimum 5-7 years coding/billing for provider medical services
Exemplary written and oral communication skills; ability to navigate challenging conversations and provide effective provider education required
Strong computer skills including proficiency with Microsoft Office products including Word, Excel, PowerPoint, and Outlook required
Extensive knowledge and proficiency of CPT & ICD-10-CM guidelines required
Self-directed and ability to work well both independently and with others
Certification from the American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC) or Certified Coding Specialist (CSS)
CPC or CCS required
Must be able to withstand stress and demands of an active position
Must be able to withstand 6-7 hours of standing, walking, stooping, bending, and sitting.
Manual dexterity, good eye/hand coordination and adequate vision and hearing needed in daily work
Must be able to work in an active open work environment
Must be able to read, write and speak English fluently
Must be able to work as a team member with peers, other departments, staffs, and administration
Must have an ability to react effectively
Must be able to set goals, organize, and prioritize work
Must maintain a positive, professional appearance and attitude

Nice To Haves

Bachelor's degree
8-10 years' experience
Experience with professional fees auditing, monitoring, and analysis including provider utilization, statistical risk assessment and report development preferred
Experience with presenting and training of E&M guidelines and coding preferred
Additional software experience with EPIC, E&M University, 3M Encoder and other coding related tools desirable
Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) highly desirable

Responsibilities

Works directly with the Privacy Officer and Compliance Director, VP Corporate Integrity, medical directors, the organization's leadership, and others to provide leadership, oversight and direction to ongoing activities related to E&M services
Oversees, directs and monitors the development, implementation, and maintenance of the organization's E&M auditing and monitoring policies and procedures
Serves as the organization's authoritative, content expert related to E&M services
Reports and or presents compliance data, documentation, and other information, as requested, or needed, to the Privacy Officer and Compliance Director, the VP Corporate Integrity, executive leadership, or management as designated
Develops and oversees the implementation of corrective action plans that result from auditing and monitoring activities, including the development of electronic templates to support documentation requirements
Develops and implements E&M educational programs and tools for providers, resident physicians, coders, and others as appropriate
Serves as advisors and educational support to the residency program through the development of educational programs for residents during their practice management elective and administers direct face-to-face didactic instruction including review of specific E&M scenarios
Initiates, facilitates, and promotes activities to foster E&M compliance awareness within the organization and related entities
Administers the process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the organization's E&M compliance and resolves customer concerns and complaints regarding specific E&M services and provides supporting information to providers, practices and patient financial services, as appropriate
Maintains current knowledge of applicable federal and state laws, E&M guidelines and associated standards, and monitors changes and new developments to ensure organizational adaptation and compliance
Monitors the OIG's work plan, CMS and other regulatory agencies and current industry standards relative to E&M focus audit activities
Analyzes auditing and monitoring outcomes and develops initiatives and feedback for the annual Compliance Plan based on identified risks
Monitors organizational, governmental, agency and other news and publications to stay informed and knowledgeable in E&M services, HCPCS, CPT and ICD-10, as appropriate
Prepares scripts to electronically query specific data elements available from software applications to collect and analyze complex data of providers' coding, billing, and utilization patterns
Develops methodologies to assess data elements to support E&M compliance for providers through analysis of billing and utilization patterns, performs routine, and focus audits and develops comprehensive educational sessions to improve performance based on the findings, as appropriate
Develop risk assessment and management strategies that support the organization's compliance audit plan
Collaborate with the organization to evaluate appropriate documentation, coding and billing and recommend, develop, or research tools and information to support these activities
Provides evaluation and resolution, with authority, of complex reimbursement issues and inquiries originating from the professional billing staff, coding staff, patients, and other internal and external customers
Act as content experts related to specific E&M matters through research, review and development of comprehensive education and training programs
Provide periodic education and training with regard to National Correct Coding Initiatives and other industry recognized E&M coding standards
Assist in the development, review and revisions of pertinent auditing and monitoring plans, action plans and education plans based on audit findings, audit outcomes, industry trends, government and other oversight notices and other internal and external factors, as appropriate
Acts in a leadership role to Compliance Audit Specialists and others with regards to training, mentoring, directing, planning, and coordinating the auditing and monitoring of professional fees and services
Act as a consultant to internal and external customers regarding provider documentation, coding, and billing, as appropriate
Supports compliance and disseminates information to improve awareness and modify policies as needed
Directs and or Attends compliance and related meetings as appropriate
Assists in other matters, as directed