Senior Compliance Auditor

Job Summary

Safeguards Montefiore Medical Center revenue and reputation, through the following activities:

• Participates in external government audits, including:NY Office of Medicaid Inspector General (OMIG)Office of Inspector General (OIG)Medicaid Fraud Control Unit (MFCU)NY Attorney General (AG)NY Department of Health (DOH)Centers for Medicare and Medicaid Services (CMS)National Government Services (NGS)Medicaid Integrity Program Contractor (MIC)Recovery Audit Contractor (RAC)Zone Program Integrity Contractor (ZPIC)Health Care Fraud Prevention and Enforcement Action Team (HEAT)
• Communicates with external agencies regarding audits.
• Participates in development of voluntary disclosures and repayments to federal and state agencies.
• Captures and presents audit findings and recommendations to senior management.
• Coordinates, supervises, and performs medical record audits of documentation, coding and billing for technical and professional services.
• Audits and enforces compliance policies and procedures.
• Develops and conducts documentation, coding and billing curriculum and education classes for 500 + physicians, allied health professionals, and coding and billing associates annually.
• Assists with distribution of all Medicare and DOH updates and code changes to the appropriate associates.
• Facilitates responses to compliance-related inquiries (phone, e-mail, in-person).

Essential Functions

• Participates in external government audits, including: NY Office of Medicaid Inspector General (OMIG) Office of Inspector General (OIG) Medicaid Fraud Control Unit (MFCU) NY Attorney General (AG) NY Department of Health (DOH) Centers for Medicare and Medicaid Services (CMS) National Government Services (NGS) Medicaid Integrity Program Contractor (MIC) Recovery Audit Contractor (RAC) Zone Program Integrity Contractor (ZPIC) Health Care Fraud Prevention and Enforcement Action Team (HEAT)
• Ensures timely and accurate response to external audit, in order to mitigate Medical Center risk (financial and reputational) imposed by regulatory agencies.
• Tracks final audit result (repayment amount) versus initial audit repayment request).
• Captures and presents audit findings and recommendations to senior management.
• Coordinates, supervises, and performs medical record audits of documentation, coding and billing for technical and professional services, including: CPT ICD9 HCPC II DRG APC APG Modifiers Teaching Physician Guidelines Non-Physician Practitioner Documentation (including "incident-to" guidelines).
• Mitigates risk of audits, corporate integrity agreements, fines etc. imposed by regulatory agencies.
• Monitors level of compliance/adherence to rules and regulations on the federal, state, and local level through regular and ongoing audit activities.
• Audits and enforces compliance policies and procedures.
• Ensures MMC employees understand and comply with rules and regulations.
• Ensures all encounter forms are accurate and up to date.
• Ensures documentation templates are in compliance with established rules and regulations.
• Reviews updated forms.
• Develops and conducts documentation, coding and billing curriculum and education classes for 500 + physicians, allied health professionals, and coding and billing associates annually, including: One-on-one education sessions based on audit findings Topic-specific group education Mandatory Compliance education Compliance Monthly education calendar sessions Grand Rounds Monthly Faculty Meetings.
• Ensures that the Medical Center has documented evidence of its commitment to compliance and training.
• Ensures that training occurs frequently and ongoing, as mandated by NY OMIG.
• Increases associate awareness of rules and regulations.

Qualifications

• Bachelor Degree Required
• Minimum 5 Years of Billing, Coding, and Documentation experience in a hospital setting
• Coding certification (such as CCS, CPC, RHIA, RHIT)
• Familiarity with both facility and professional documentation, coding and billing rules and regulations
• Able to navigate registration, billing, and documentation systems with ease
• Knowledge of local, state, and federal rules and regulations
• Able to communicate with all levels of associates, including senior management and external agencies
• Excellent written and oral communication skills
• Highly organized and analytical individual
• Needs to be able to function with a high level of independence, motivate and train associates while maintaining good working relationships