Compliance Analyst II

Responsibilities

• Provides compliance oversight and support for assigned clinical specialties across URMC and Affiliates in accordance with the OIG and OMIG compliance program guidance.
• Evaluates adherence to coding and billing regulations and guidelines through review, research, and analysis.
• Serves as a compliance resource, developing and delivering comprehensive education and training.
• Conducts investigations, risk assessments, and regulatory monitoring to prevent and detect fraud, waste, and abuse, specifically addressing the DRA, NY SSL 363-d, and 18 NYCRR SubPart 521.

Requirements

• Requires a high degree of accuracy, professional judgment, and accountability, as errors can result in significant regulatory or financial penalties or reputational risk.
• Analyzes billing data to identify potential risk areas related to professional and/or facility payment systems.
• Performs audits of medical record documentation to ensure compliance with coding and billing requirements as defined by AMA, AHA, HCPCS, CMS and Medicaid guidelines.
• Creates and provides reports on findings to relevant stakeholders.
• Responds to reported compliance concerns by conducting formal investigative activities.
• Affairs with relevant stakeholders to determine improvement opportunities to mitigate future risk.
• Collaborates with OIC leadership to determine corrective action such as formal self-disclosures or claim adjustments.
• Develops and delivers comprehensive education and training sessions for faculty, residents, and staff, covering essential topics such as coding, compliance with Medicare, Medicaid, and third-party payer billing regulations, and fraud, waste, and abuse prevention.
• Serves as a resource and subject matter expert for URMC and Affiliate personnel, offering guidance on billing, coding, and reimbursement matters.
• Assists in due diligence activities related to physician practice and provider acquisitions as directed by OIC leadership and/or Office of Counsel.
• Assists in assessing and responding to external audits and government investigations as directed.
• Participates in special projects and investigations as directed by compliance leadership and/or Office of Counsel.

Qualifications

• Minimum Education & Experience: Bachelor or Associate’s degree in a related field preferred. Equivalent combination of education, professional certification(s), and substantial relevant experience will also be considered. Minimum of 3 years of healthcare coding experience required to include APG, APC, and/or DRG coding methodologies or professional coding and billing in specialty areas. Experience in a direct or supporting role within healthcare compliance preferably within an integrated health system or Academic Medical Center or other comparable setting.

Skills and Abilities

• Strong communication, interpersonal, and public speaking skills required.
• Ability to efficiently produce clear, concise, and complete written audit reports required.
• Excellent analytical, organizational, and problem-solving skills required.
• Demonstrated objectivity and critical thinking in analyzing situations; must be able to evaluate facts without bias and avoid unsupported assumptions required.
• Ability to manage projects and effectively advise staff in a motivational and positive manner required.
• Willingness to collaborate with others and to work as part of a team required.
• Ability to maintain high discretion and confidentiality with sensitive information required.
• Experience creating, editing, and manipulating data and documents using Microsoft Office required.

License and Certifications

• One of the following credentials are required: Registered Health Information Technologist (RHIT), Registered Health Informational Administrator (RHIA), Certified Coding Specialist (CCS or CCS-P), Certified Professional Coder (CPC), or Certified Outpatient Coder (COC) or equivalent professional certification. Certified in Healthcare Compliance (CHC) preferred.