Description

Roles and Responsibilities The Compliance Auditor is responsible for planning and conducting audits for clinical and administrative processes, including coding and billing compliance, documentation, medical necessity, adherence to internal policies, procedures and guidelines, services provided by outside vendors including revenue cycle vendor, and compliance with state and federal regulations including HIPAA Privacy and Security. The Compliance Auditor is responsible for preparing and submitting written audit reports that include findings and recommendations, communicating findings to the Director, developing and implementing corrective action plans when necessary, and following up to ensure that corrective plans are implemented and were effective. Desired Candidate Profile Implement the Audit Process Plan and schedule audits, including identifying the audit subject and purpose, defining audit objective(s), defining audit scope, performing pre-audit planning, and notification to the area(s) to be audited. Conduct audits, including meeting with impacted employees and keeping impacted organizational areas(s) apprised along the way of any findings and urgent actions to be taken if necessary. Develop audit reports that includes findings, recommendations designed to correct any potential weaknesses or areas of noncompliance discovered during the audit, request for management response to each finding or recommendation including corrective action plan(s) to be developed and implemented. Provide follow-up prior to closing the audit including confirming successful implementation of corrective action plans, verify that management responses are implemented, and assess new processes, procedures and actions. Stay Abreast of Applicable Regulatory Changes Maintain current knowledge of medical documentation, fraud, abuse, and documentation and coding violations based on governmental guidelines, including State and Federal overpayment regulations. Stay abreast of and maintain current knowledge of Medicare and Medicaid guidelines applicable to Pain Management Clinics and Ambulatory Surgical Centers (ASCs), including applicable Local Coverage Determinations (LCDs). Maintain current knowledge of requirements and guidance required in the performance of audit duties, including but not limited to ICD-10, HCPCS, and CPT coding, modifiers, and surgical procedures documentation requirements. Maintain current knowledge of HIPAA Privacy and Security Requirements. Conduct Audits Review medical records to determine the medical necessity of services billed and the accuracy of coding, billing, and supporting clinical documentation in either an Ambulatory Surgical Center (ASC) or a Pain Management Clinic. Review records that have been reviewed and coded by the revenue cycle vendor. Review client practices, procedures, and materials for compliance with CMS and HIPAA regulations. Prepare audit reports of findings and observations that identify, in detail, areas of non- compliance and risk areas for non-compliance. Ensure corrective actions are implemented and effective. Conduct other audits as assigned, including but not limited to contract reviews, lease agreements, compliance with contract language, etc. Share departmental responsibilities as assigned. JOB REQUIREMENTS Bachelors degree in accounting, business administration, or healthcare related field required. AAPC Certified Professional Coder (CPC) or AHIMA Certified Coding Specialist Physician-based (CCS-P) certification, required. Certified Professional Medical Auditor (CPMA) certification preferred. Healthcare compliance certification, a plus. A strong understanding of healthcare regulations, such as HIPAA, Medicare, Medicaid, and other relevant industry standards, is essential. Solid grasp of auditing principles, techniques, and methodologies. Experience working autonomously. Healthcare auditing, billing/coding experience, required. A minimum of 5 years experience in a healthcare compliance. KNOWLEDGE, SKILLS AND ABILITIES: Knowledge of federal (including HIPAA) and state regulatory requirements. Strong analytical and critical thinking skills. Attention to detail and the ability to think strategically. Excellent written and verbal communication skills to present findings and results effectively. Ability to work well in a team, contribute effectively, and manage priorities. Good computer software skills and knowledge. Knowledge of data analysis and audit software tools is a plus.

Role and Responsibilities

• Roles and Responsibilities The Compliance Auditor is responsible for planning and conducting audits for clinical and administrative processes, including coding and billing compliance, documentation, medical necessity, adherence to internal policies, procedures and guidelines, services provided by outside vendors including revenue cycle vendor, and compliance with state and federal regulations including HIPAA Privacy and Security. The Compliance Auditor is responsible for preparing and submitting written audit reports that include findings and recommendations, communicating findings to the Director, developing and implementing corrective action plans when necessary, and following up to ensure that corrective plans are implemented and were effective. Desired Candidate Profile Implement the Audit Process Plan and schedule audits, including identifying the audit subject and purpose, defining audit objective(s), defining audit scope, performing pre-audit planning, and notification to the area(s) to be audited. Conduct audits, including meeting with impacted employees and keeping impacted organizational areas(s) apprised along the way of any findings and urgent actions to be taken if necessary. Develop audit reports that includes findings, recommendations designed to correct any potential weaknesses or areas of noncompliance discovered during the audit, request for management response to each finding or recommendation including corrective action plan(s) to be developed and implemented. Provide follow-up prior to closing the audit including confirming successful implementation of corrective action plans, verify that management responses are implemented, and assess new processes, procedures and actions. Stay Abreast of Applicable Regulatory Changes Maintain current knowledge of medical documentation, fraud, abuse, and documentation and coding violations based on governmental guidelines, including State and Federal overpayment regulations. Stay abreast of and maintain current knowledge of Medicare and Medicaid guidelines applicable to Pain Management Clinics and Ambulatory Surgical Centers (ASCs), including applicable Local Coverage Determinations (LCDs). Maintain current knowledge of requirements and guidance required in the performance of audit duties, including but not limited to ICD-10, HCPCS, and CPT coding, modifiers, and surgical procedures documentation requirements. Maintain current knowledge of HIPAA Privacy and Security Requirements. Conduct Audits Review medical records to determine the medical necessity of services billed and the accuracy of coding, billing, and supporting clinical documentation in either an Ambulatory Surgical Center (ASC) or a Pain Management Clinic. Review records that have been reviewed and coded by the revenue cycle vendor. Review client practices, procedures, and materials for compliance with CMS and HIPAA regulations. Prepare audit reports of findings and observations that identify, in detail, areas of non- compliance and risk areas for non-compliance. Ensure corrective actions are implemented and effective. Conduct other audits as assigned, including but not limited to contract reviews, lease agreements, compliance with contract language, etc. Share departmental responsibilities as assigned. JOB REQUIREMENTS Bachelors degree in accounting, business administration, or healthcare related field required. AAPC Certified Professional Coder (CPC) or AHIMA Certified Coding Specialist Physician-based (CCS-P) certification, required. Certified Professional Medical Auditor (CPMA) certification preferred. Healthcare compliance certification, a plus. A strong understanding of healthcare regulations, such as HIPAA, Medicare, Medicaid, and other relevant industry standards, is essential. Solid grasp of auditing principles, techniques, and methodologies. Experience working autonomously. Healthcare auditing, billing/coding experience, required. A minimum of 5 years experience in a healthcare compliance. KNOWLEDGE, SKILLS AND ABILITIES: Knowledge of federal (including HIPAA) and state regulatory requirements. Strong analytical and critical thinking skills. Attention to detail and the ability to think strategically. Excellent written and verbal communication skills to present findings and results effectively. Ability to work well in a team, contribute effectively, and manage priorities. Good computer software skills and knowledge. Knowledge of data analysis and audit software tools is a plus.