Compliance Auditor Senior

Essential Responsibilities

• Evaluates the progress of team members including review of reports and audit activities.
• Works with senior management responsible for AHN-wide case management/physician programs to develop processes that meet Medicare and 3rd party payor requirements.
• Provides guidance to staff auditors on audit topics and reports.
• Conducts educational sessions for hospital/physician staff.
• Conducts investigations and performs special projects as assigned.
• Compliance Auditor- Sr. (Clinical Specialty): Audits/oversees the auditing of 340B program and provides guidance to 340B management team.
• Participates in meetings specific to case management/UR and assists with 340B regulatory requirements and when needed, monitors corrective actions.
• Analyzes and summarizes PEPPER reports and recommends high risk areas for audit.
• Conducts audits of Medicare/Medicaid and other third party payor accounts for documentation, medical necessity, coding (non DRG), charging, billing and compliance with state and federal regulations.
• Prepares accurate and concise written audit reports.
• Works with auditees on corrective action plans and educate management, physicians, utilization review/case management staff and/or hospital personnel on documentation, billing, coding requirements.
• Responds to external audits of the government (facility based) sent to the compliance office and works with operational owners to establish and implement corrective actions when needed.
• Advises UR/CM in defending payor claims denials for medical necessity, coding, billing and documentation through coordination of and/or participation (when appropriate) in the appeal process (RACS, ZPICs, MICs and OIG audits in particular and other payors as assigned.)

Qualifications

• Minimum: Bachelor's degree in nursing for Compliance Auditor - Sr. (Clinical Specialty); Bachelor's degree or equivalent education and related experience for Compliance Auditor - Sr. (Clinical Specialty AND Physician Specialty); Master’s degree for Compliance Auditor - Sr. (Clinical Specialty).
• Preferred: Master’s degree for Compliance Auditor - Sr. (Clinical Specialty); RHIT, RHIA certification for Compliance Auditor - Sr. (Clinical Specialty AND Physician Specialty).
• Knowledge of a variety of clinical specialty areas, practices and procedures as well as 340B program.