Enterprise Provider Compliance Auditor-Educator

About the role

The Enterprise Compliance Auditor/Educator will assist with the implementation and facilitation of ongoing compliance auditing, monitoring, and education associated with all provider services across WVUHS and its affiliates. This position helps ensure that all healthcare provider (MD/DO, APP, and other non-physician practitioners) organizations remain in compliance with federal healthcare program rules, regulations, administrative requirements, and guidance.

Responsibilities

• Conducts compliance-related audits and reviews, coordinating with departments to ensure adherence to CMS, multistate (WV, OH, PA, MD, etc.), and payor-specific regulations for chart documentation, valid coding and billing, and medical necessity support to prevent fraud, waste, and abuse as mandated by OIG compliance program requirements.
• Coordinates audits across WVUHS and all its affiliates, evaluating the scope of the audit and developing/completing data analytical reports to identify the audit universe and select appropriate samples.
• Formulates and defines, alongside the Director of Provider Compliance and VP of Corporate Compliance, the scope and objectives of audits or reviews, researching relevant regulatory requirements.
• Reviews medical records, billing, or other relevant documentation, developing and writing audit reports that outline findings, recommendations, and corrective actions.
• Leads meetings with departments or individuals to review audit reports and develop corrective action plans.
• Plans, develops, and conducts presentations for internal and external departments to meet organizational compliance education needs.
• Conducts and/or facilitates audit training and education activities, including individual or group training based on internal audit results.
• Reviews clinical issues with physicians to ensure appropriate documentation, coding, and reimbursement.
• Assists in planning informational programs, education, and training sessions on current and changing compliance and regulatory requirements.
• Develops and conducts ongoing compliance, documentation guidelines, and billing education for new staff, including physicians, allied health professionals, advanced practice professionals, and coding personnel.
• Acts as a subject matter expert to the Enterprise Information Management team for both professional and hospital coding.
• Assists in reviewing new or revised regulations or policies to determine their applicability at UHA and other provider groups.
• Conducts ongoing auditing, monitoring, and/or investigations related to compliance with policies and regulatory requirements.
• Assists in compiling compliance statistics, findings, and status updates for reporting.
• Prepares and submits summaries of completed audits for provider board of director and compliance/audit committees, including subject background, findings, recommendations, and corrective actions.
• Serves as a compliance representative on assigned teams or committees to provide input and ensure compliance with applicable laws, regulations, and policies.

Requirements

• High School Diploma or Equivalent and seven (7) years of experience in multi-specialty coding, E&M coding, procedural/surgical coding, or
• Associate’s Degree and five (5) years of experience in multi-specialty coding, E&M coding, procedural/surgical coding.
• Current certification in one of the following:
  • Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC)
  • Registered Health Information Technician (RHIT) through the American Health Information Management Association (AHIMA)
  • Certified Coding Specialist-Physician (CCS-P) through the American Health Information Management Association (AHIMA)

Preferred Qualifications

• Bachelor’s Degree.

Skills

• Knowledge of provider healthcare compliance, revenue cycle operations, and auditing techniques.
• Analytical and problem-solving skills.
• Effective verbal and written communication skills, as well as interpersonal skills for interacting with all levels of management.
• Ability to work on assignments of varying difficulty and complexity while exercising independent judgment.
• Proficiency with personal computers and financial application software.
• Excellent organizational and time management skills.
• Excellent presentation skills.
• Ability to utilize electronic medical record and billing systems.
• Ability to analyze complex EMR workflows related to documentation, billing, etc.
• Knowledge of governmental billing and coding regulations, including the “Teaching Physician Guidelines.”

Physical Requirements

• Extended periods of sitting.
• Extended periods of computer and telephone usage.
• May require large amounts of walking.
• May require ability to lift and/or carry heavy materials (e.g., written records, reference manuals, files).

Working Environment

Standard office environment.

Schedule

Scheduled Weekly Hours: 40

Shift: Day