Compliance Auditor

Position Summary

The Compliance Auditor plans, schedules, and performs comprehensive internal professional fee audits to include routine audits, focused audits, for cause audits and, not for cause audits for Chesapeake Regional Healthcare (CRH) and all of its affiliated entities. Performs detection of documentation, coding, and billing errors as well as collaboration with appropriate stakeholders to ensure corrective action and/or appropriate response to identified issues. Communicates audit results to providers, coders, management, and other appropriate staff. Develops and delivers provider and coder education. Evaluates the effectiveness of internal controls designed to ensure that processes and practices lead to regulatory compliance with guidelines related to professional fee documentation, coding, and billing. Stays abreast of documentation, coding, and billing regulations and standards and serves as a subject matter expert on the interpretation and application of documentation, along with coding rules and regulations.

Essential Duties And Responsibilities

• Plans, schedules, and performs comprehensive internal professional and hospital fee audits as determined by the Compliance Work Plan to include routine and focused audits.
• Detection of documentation, coding, and billing errors as well as collaboration with appropriate stakeholders to ensure corrective action and/or appropriate responses are implemented to address identified issues.
• Communicates audit results to providers, coders, management, and other appropriate staff and makes recommendations to ensure sustained compliance and improvement.
• Develops and delivers provider and coder education, as needed.
• Evaluates the effectiveness of internal controls designed to ensure that processes and practices lead to regulatory compliance with guidelines related to professional and hospital fee documentation, coding, and billing, including federal and state regulations, CMS, and OIG compliance standards.
• Serves as subject matter expert on interpretation and application of documentation and coding rules and regulations.
• Develops compliance auditing plans based on thorough research on studies conducted by government agencies and professional organizations.
• Compiles reports on the results of external and internal audits and presents these reports to the relevant supervisors and department heads.
• Performs audits according to the established Compliance Work Plan and calendar and prepares Compliance Work Plan summary slides with appropriate corrective action plans.
• Affords assistance with the modification of the Compliance Work Plan calendar through the year to include additional audits, based on audit results, risks, and corrective action plans.
• Affords assistance to the Compliance Committee and presents summary of audit activities to the committee.
• Provides results of audits and education to HIM, Revenue Cycle Departments, physicians, hospital and clinic operations regarding charging, documentation, and billing requirements.
• Affords assistance in developing corrective action plans (CAPs), as needed, and ensures CAPs are implemented and evaluated for effectiveness by performing follow up audits/reviews in a timely manner.
• Communicates effectively with the Corporate Compliance team and CRH and all of its affiliated entities departments following the CRH Code of Conduct.
• Performs medical record audits of documentation, coding and billing for technical and professional services, including: CPT; ICD10; HCPCII; DRG; APC; APG; Modifiers; Non-Physician Practitioner Documentation (including “incident-to” guidelines), and other services; Conducts audits of electronic and manual documentation, coding, and billing systems.
• Develops formal audit reports of findings and recommendations, which are presented to senior management of applicable department, the Corporate Compliance Committee and Operations Quality and Safety Committee.
• Participates in external government audits, including but not limited to: Centers for Medicare and Medicaid Services (CMS); Office of Inspector General (OIG); Medicaid Fraud Control Unit (MFCU); Virginia Department of Health (DOH); Medicaid Integrity Program Contractor (MIC); Recovery Audit Contractor (RAC); Zone Program Integrity Contractor (ZPIC); Health Care Fraud Prevention and Enforcement Action Team (HEAT)
• Participates in development of voluntary disclosures and repayments to federal and state agencies.
• Conducts opening and closing meetings with senior management of applicable department being audited.
• Identifies compliance risk areas and develops action plans accordingly.
• Develops and coordinates analysis of encounter forms and documentation templates.
• Audits and enforces compliance policies and procedures.
• Develops and conducts documentation, coding and billing curriculum and education classes for more than 100 physicians, allied health professionals, and coding and billing associates annually.
• Affords assistance in development of risk areas and audit creation.
• Affords assistance in distribution of all Medicare and Virginia Department of Health updates and code changes to the appropriate associates.
• Facilitates responses to compliance-related inquiries (phone, e-mail, in-person).
• Responsible for other matters as assigned by the Chief Corporate Compliance Officer and/or Corporate Compliance Manager and Auditor.

Ideal Candidate Attributes

• Pays close attention to detail and strives for excellence.
• Possesses curiosity for learning CRH’s business, products and solutions.
• Thrives in a dynamic environment by practicing effective time management and prioritization of tasks.
• Comfortable in making recommendations in compliance, audit, and contractual matters.
• Effectively assists cross-functional projects to completion.
• Displays strong communication and writing skills.
• Displays excellent judgment and strong organizational skills.
• Displays a willingness and ability to work and coordinate activities across a large number of individuals in various departments.
• Ability to pass required background checks and clearances.

Minimum Qualifications And Requirements

• Experience as a coder in a hospital and/or healthcare environment.
• Extensive knowledge of evaluation and management coding, modifiers, provider-based billing, and auditing principles.
• American Academy of Professional Coders (AAPC) coding certification (such as Certified Professional Coder (CPC) or dual CPC and Certified Professional Biller (CPB)) or to obtain within one (1) year of hire.
• An in-depth understanding of the industry's rules, guidelines, and regulations.
• Strong attention to detail, analytical, and statistical skills.
• Strong communication and multitasking skills.
• Dedication to objectivity.
• Experience in healthcare revenue cycle, auditing, clinical operations and/or compliance preferred.
• Knowledge of DRG, CPT, CDM and billing operations.
• Knowledge of hospital department operations.
• Knowledge and experience with EPIC and Athena electronic medical records.
• Strong Skills with Microsoft products (Excel, Word, and Power Point).
• Strong verbal and written communication skills.

Preferred Qualifications

• Three (3) years auditing experience in a hospital and/or healthcare environment.
• Auditing certification such as Certified Professional Medical Auditor (CPMA) or other accredited auditing certification.
• Bachelor’s degree in Nursing, Healthcare Administration, Business, and/or Accounting.
• Health Care Compliance Association (HCCA) membership and certification.