Job Summary and Responsibilities: The Compliance Specialist is responsible for assuring on-going compliance by actively participating in the Compliance Program. In consultation with the Chief Compliance Officer the Compliance Specialist proactively assesses changes in the regulatory environment; researches, investigates and responds to issues related to accreditation, documentation, coding and licensure. Coordinates and participates in the record/claims review process, provides documentation and compliance education sessions to physicians and other staff. The Compliance Specialist may assist the Chief Compliance Officer with other aspects of the Compliance Program to assure compliance with licensure, accreditation and other applicable state and federal regulations.
1. Investigates, responds to and communicates information regarding accreditation, documentation, coding, compliance and reimbursement.
a. Facilitates timely, accurate and complete documentation.
b. Assists in identifying appropriate documentation requirements for specialized services.
c. Support, provide analysis for and advise senior management regarding coding and documentation impact on accreditation, revenue and reimbursement issues.
d. Analyze and trend coding issues/questions from both a compliance and regulatory perspective.
e. Works with Health Information Staff to assure appropriate documentation standards in support of ethical coding and data abstraction for public reporting. Ensures the appropriate dissemination and communication of regulation, policy and guideline changes to affected personnel
2. Provide compliance/documentation education to physicians and other staff as requested.
a. Provide accurate and up to date information on regulatory and reimbursement requirements.
b. Provide documentation and coding expertise for all compliance and reimbursement issues
c. Prepare reports and graphics for presentation.
d. Maintain attendance lists for all presentations and log of issues raised and identified for future research and response
e. Develop educational materials related to documentation, compliance and reimbursement, for physicians and other staff.
f. Develops and maintains policies as required
3. Coordinates and perform chart reviews for outpatient and inpatient services
a. In accordance with goals established by the Chief Compliance Officer, complete reviews within established timeframes, analyze results and prepare formal reports with findings and recommendations.
b. Consult with physicians for clarification of clinical data when ambiguous information is encountered.
c. Facilitate and improve physician understanding of regulatory and payer requirements by providing feedback related to documentation information.
4. Participate in the rejections and claims review process to ensure both compliance and the maximization of appropriate departmental reimbursement.
a. Participate in regular meetings with billing, abstraction and reimbursement staff to review claim rejections and develop appropriate strategies for addressing them.
b. Review requests from insurers and patient families for copies of patient medical charts and/or changes in codes/fees.
c. Participate in the development and implementation of systems/procedures related to rejection and follow-up strategies.
5. Participate as an active member Compliance Coordination Team and other teams assigned in support of the Compliance Program.
a. Attend regular meetings, reporting on projects and findings as requested.
b. Perform special projects/tasks/reviews as designated by the Compliance Officer.
Working Conditions: Lifts a minimum of 10 Lbs., pushes and pulls a minimum of 20 lbs. and stands a minimum of 2 hours a day
Education, Knowledge, Skills and Abilities Required:
1. BA/BS required.
2. Computer proficiency and demonstrated presentation skills required.
3. Clinical experience.
Education, Knowledge, Skills and Abilities Preferred:
1. Familiarity with JCAHO, NJ State DHSS and CMS regulations required with corporate compliance implementation preferred.
2. Minimum of 5 years coding and 2 years audit experience in a hospital, consulting firm or practice management setting.
3. Proficiency with medical terminology and ICD-9-CM and CPT-4 methodologies.
4. Proficiency with physician documentation and reimbursement methodologies.
Licenses and Certifications Required:
Licenses and Certifications Preferred:
1. NJ State Professional Registered Nurse License.
2. Registered Health Information Administrator Certification or Registered Health Info Tech License or Certified Professional Coder or Certified Coding Specialist.
Job ID 19787