Senior Compliance Investigation Auditor

UIOWA•Iowa City, IA

About The Position

The Senior Compliance Investigation Auditor , within the Joint Office for Compliance (JOC), is responsible for the activities related to the coding, billing, and documentation investigations. This position ensures adherence to UI Health Care’s Overpayment Investigation and Return Policy, and federal rules and regulations related to coding and billing activities. Position responsibilities: Perform investigation audits in accordance with UI Health Care policies and guidelines, federal rules and regulations, and other guidelines governing compliant coding, billing, and documentation. Adhere to audit scope and perform high level, self-guided research on all required topics (coding/billing rules, federal regulations and manual guidance, commercial payor policy, internal policy, etc.) necessary to perform audit. Maintain a high level of understanding and awareness of CPT/HCPCS guidelines and federal coding and billing regulations/guidance, compliance program standards, and documentation requirements. Utilize RAT-STATS to identify random samples and statistical values in extrapolating overpayments. Analyze data based on audit scope to determine relevance or potential need for updated parameters. Track and organize findings, communication, resources, and all other items pertaining to audits in shared folders in an accurate and timely manner. Ensure timely reporting and validation of investigation audit findings, adhering to applicable UI Health Care policies/procedures. Discuss findings with JOC Investigation Supervisor, and other leaders as needed. Compose detailed summaries of audit findings to be sent via email to providers, clinical department administrators, coders, and other hospital staff in a timely manner. Communicate and resolve issues and disagreements with coding and providers as they arise during audit. Conduct audit meetings, in person or virtually, related to findings with providers, coders, and clinical department administrators, requiring a high level of organization and communication for quality delivery of results. Follow up with key stakeholders to ensure completion/implementation of corrective actions. Prepare complex reports to be presented to JOC leadership that detail audit process, findings and trends, and corrective action. Maintain and adhere to unit’s SOP documents.

Requirements

A Bachelor’s Degree in Health Information Management or related field, or equivalent combination of education and experience is required.
Certification as RHIT, RHIA, CPC, or equivalent through a nationally recognized credentialing body such as AHIMA or AAPC.
3 years of coding experience (inpatient, outpatient, professional, hospital or a combination).
Considerable knowledge of various coding systems used by hospitals and physicians including ICD-9-CM, ICD-10-CM/PCS, CPT, HCPCS.
Excellent written and verbal and interpersonal communication skills.
Proficient in computer software applications.
Adaptability, creative problem solving, project management and organizational skills.
Knowledge of team dynamics and skilled in building consensus .
Ability to develop and maintain effective relationships with internal and external partners .

Nice To Haves

1-3 years of experience in coding education and training
Strong knowledge of compliance as it relates to a teaching environment.
Knowledge of hospital inpatient, outpatient, and professional billing concepts which includes Medicare Severity Diagnosis Related Groups (MSDRG), Ambulatory Payment Classification (APC)/Ambulatory Patient Groups (APG), Resource Based Relative Value Scale (RBRV) and additional managed care and capitated arrangements.
Experience with auditing, summarizing and discussing medical coding findings with providers.
Knowledge of computer systems, such as coding encoders, Diagnosis Related Group (DRG) analyzers and computer-assisted coding.
Knowledge of various payor billing requirements as well as billing rules and regulations for Medicare, Medicaid, and other federal payor plans.
Knowledge of University policies, procedures, and regulations.

Responsibilities

Perform investigation audits in accordance with UI Health Care policies and guidelines, federal rules and regulations, and other guidelines governing compliant coding, billing, and documentation.
Adhere to audit scope and perform high level, self-guided research on all required topics (coding/billing rules, federal regulations and manual guidance, commercial payor policy, internal policy, etc.) necessary to perform audit.
Maintain a high level of understanding and awareness of CPT/HCPCS guidelines and federal coding and billing regulations/guidance, compliance program standards, and documentation requirements.
Utilize RAT-STATS to identify random samples and statistical values in extrapolating overpayments.
Analyze data based on audit scope to determine relevance or potential need for updated parameters.
Track and organize findings, communication, resources, and all other items pertaining to audits in shared folders in an accurate and timely manner.
Ensure timely reporting and validation of investigation audit findings, adhering to applicable UI Health Care policies/procedures.
Discuss findings with JOC Investigation Supervisor, and other leaders as needed.
Compose detailed summaries of audit findings to be sent via email to providers, clinical department administrators, coders, and other hospital staff in a timely manner.
Communicate and resolve issues and disagreements with coding and providers as they arise during audit.
Conduct audit meetings, in person or virtually, related to findings with providers, coders, and clinical department administrators, requiring a high level of organization and communication for quality delivery of results.
Follow up with key stakeholders to ensure completion/implementation of corrective actions.
Prepare complex reports to be presented to JOC leadership that detail audit process, findings and trends, and corrective action.
Maintain and adhere to unit’s SOP documents.