Understand and maintain strict professional confidentiality of patient information, work plans and projects.
Maintain abreast of compliance issues related to the healthcare industry, annual coding updates and frequent regulatory changes.
Exercise due professional care in performing internal audits and compliance reviews. In addition, the Physician Compliance Audit Manager shall possess the knowledge, skills and disciplines essential to the performance of compliance reviews.
Coordinate and supervise the Senior Physician Compliance Auditors and Physician Compliance Auditors in collaboration with the Director of Compliance/SVP, Internal Audit & Compliance.
Coordinate and perform educational training programs consisting of appropriate documentation guidelines and accurate coding to all appropriate personnel, including coding staff, physicians, billing personnel and ancillary departments.
Conduct regular audits and coordinate the monitoring of coding and documentation accuracy; reviewing claim denials and rejections pertaining to coding and medical necessity issues. When necessary, assist in the implementation of corrective action plans, such as educational programs, to prevent similar denials and rejections from recurring.
When planning, performing and reporting compliance reviews, the Physician Compliance Audit Manager shall:
Determine the scope, objectives and approach of each review to be performed
Prepare compliance review plans with emphasis on clearly describing the various auditing procedures to be used and the key points in the area to which they will be applied.
Collect, analyze, interpret and document information to supportaudit findings.
Prepare auditreports to document area under review, procedures performed and conclusions met.
Perform oral presentations to all levels of management throughout the review, discussing review objectives and approach, deficiencies found (if any), and recommendations for improvement.
Appraise adequacy of management's response to recommendations cited in oral and written reports.
Provide individualized feedback and information to providers as it relates to the compliance audits being performed.
Conduct annual audits as it relates to the Office of the Inspector General (OIG) and Office of the Medicaid Inspector General (OMIG) work plans to ensure adherence with Federal and State guidelines.
Perform annual review of physician charge tickets to ensure compliance with annual coding updates.
Report noncompliance issues detected through auditing and monitoring, nature of corrective action plans, and results of follow-up audits to the Vice President and the respective Entity Compliance Officer.
Serve as a resource for department managers, staff, physicians and administration to obtain information on accurate and ethical coding and documentation standards, guidelines and regulatory requirements.
Obtain access to technologies and other resources which provide up to date releases on changes in laws, rules and regulations. Provide research and support for special projects within CHS.
Bachelordegreerequired. CPC or CCS-P certification required.
50 - 75% travel to other CHS Entities.
A minimum of five years of physician billing auditing experience is required. Extensive knowledge of ICD-9, ICD-10 and CPT coding principles, guidelines and practices is required.
Shall possess the knowledge, skills and disciplines essential to the performance of physician compliance reviews of healthcare institutions, as follows:
A strong knowledge base in complete and accurate clinical documentation.
A strong knowledge of Federal and State health care regulations, standards, policies and requirements pertaining to documentation, coding and billing.
The ability to accurately interpret and implement regulatory standards and legal requirements.
Strong analytical and problem-solving skills and have expertise in report writing and oral communications.
Strong professional attitude and have the ability to work with and communicate effectively with all levels of management and personnel.
Strong computer skills, particularly in Microsoft Word and Excel.