Senior Compliance Audit Specialist

Core Job Responsibilities

• Works directly with the Privacy Officer and Compliance Director, VP Corporate Integrity, medical directors, the organization's leadership, and others to provide leadership, oversight and direction to ongoing activities related to E&M services
• Oversees, directs and monitors the development, implementation, and maintenance of the organization's E&M auditing and monitoring policies and procedures
• Serves as the organization's authoritative, content expert related to E&M services
• Reports and or presents compliance data, documentation, and other information, as requested, or needed, to the Privacy Officer and Compliance Director, the VP Corporate Integrity, executive leadership, or management as designated
• Develops and oversees the implementation of corrective action plans that result from auditing and monitoring activities, including the development of electronic templates to support documentation requirements
• Develops and implements E&M educational programs and tools for providers, resident physicians, coders, and others as appropriate
• Serves as advisors and educational support to the residency program through the development of educational programs for residents during their practice management elective and administers direct face-to-face didactic instruction including review of specific E&M scenarios
• Initiates, facilitates, and promotes activities to foster E&M compliance awareness within the organization and related entities
• Administers the process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the organization's E&M compliance and resolves customer concerns and complaints regarding specific E&M services and provides supporting information to providers, practices and patient financial services, as appropriate
• Maintains current knowledge of applicable federal and state laws, E&M guidelines and associated standards, and monitors changes and new developments to ensure organizational adaptation and compliance
• Monitors the OIG's work plan, CMS and other regulatory agencies and current industry standards relative to E&M focus audit activities
• Analyzes auditing and monitoring outcomes and develops initiatives and feedback for the annual Compliance Plan based on identified risks
• Maintains current knowledge of applicable federal and state laws, E&M guidelines and associated standards, and monitors changes and new developments to ensure organizational adaptation and compliance
• Makes recommendations, develops, or researches tools and information to support these activities
• Provides evaluation and resolution, with authority, of complex reimbursement issues and inquiries originating from the professional billing staff, coding staff, patients, and other internal and external customers
• Acts in a leadership role to Compliance Audit Specialists and others with regards to training, mentoring, directing, planning, and coordinating the auditing and monitoring of professional fees and services
• Assists in other matters, as directed

Preferred Requirements

• Preferred Education Bachelor's degree
• Preferred Experience 8-10 years' experience
• Experience with professional fees auditing, monitoring, and analysis including provider utilization, statistical risk assessment and report development preferred
• Experience with presenting and training of E&M guidelines and coding preferred
• Additional software experience with EPIC, E&M University, 3M Encoder and other coding related tools desirable