Compliance Audit and Education Specialist

Major Responsibilities:

• Plans, develops, and implements the review.  Determines scope of review, such as number of patient services, sample sizes, mix of physician/facility services, etc.  
• Reviews professional and hospital claim form documents in conjunction with patient medical record to ensure appropriate coding and clinical documentation.  Also reviews reimbursement documents to validate appropriate reimbursement, identify overpayments and/or missed opportunities. 
• Prepares presentation of findings and recommends corrective actions to ensure compliance with applicable governmental regulations and organizational policies and procedures. 
• Presents to physicians, clinicians, and/or administrative staff to educate regarding coding, billing, and documentation requirements to meet government and third-party payer requirements.  
• Reviews and responds to external audit requests surrounding supervision, coding, billing, and documentation requirements.
• Performs routine risk analyses, staying current with governmental workplans and current healthcare events.
• Remains current regarding changes in Medicare and/or Medicaid regulations.  Provides educational material and conducts training sessions for applicable organization. 
• Participates and assists in seminars on governmental coding, billing and documentation rules and regulations.

Position Qualifications:

License/Certification/Education:

Required:

• Bachelor’s degree in Business Administration, Health Care, or related field.
• Coding and/or Auditing Certification such as CPC, CPMA, CEMC, CCS, CCS-P (May consider applicants in process of obtaining with successful completion within one year).

Experience/Skills:

Required:

• Proficient in Evaluation and Management Auditing.
• Strong knowledge in performing risk-based auditing.
• Three to five years of experience with Government Payers (Medicare and Medicaid) as well as large third-party health care insurers or integrated health care delivery system, third-party billing requirements and regulations. 
• Strong working knowledge of ICD-10, CPT-4, to include HCPCS coding is essential.  
• Knowledge of charge master and/or DRG coding is a significant plus.  
• Strong oral and written communication skills and analytical and presentation skills, for interacting with all levels of leadership and staff.  
• Must be highly organized and pay strong attention to detail and accuracy.
• Proficient computer skills in Microsoft Office, i.e. Word, Excel, PowerPoint.

Preferred:

• Epic experience.
• MD Audit (Enterprise).