Summary:
The Senior Billing Compliance Analyst is responsible for ensuring compliance with applicable internal policies and procedures as well as State and Federal regulations specific to documentation, charging, coding, and billing for multiple product lines (Medicaid, Medicare and Commercial). Position will coordinate compliance activities, including but not limited to: conducting retrospective coding and billing compliance audits, ensuring contractual and regulatory requirements are met, preparing documents for program integrity and payor audit responses, prepare and provide internal education and training on billing compliance requirements, provide research and investigation support for billing compliance consults, and contribute to regulatory change management process.
Responsibilities:
* Maintains knowledge of system policies and organizational processes that support the seven (7) elements of an effective compliance program as defined by the Office of the Inspector General and at the direction of the VP Deputy Chief Compliance and Audit Officer and/or their designee.
* Serves as a key department representative for potential payor audit program contacts and agencies, and prepare audit files, provide review support, and denial, appeal and education support and follow-up.
* Develops general compliance educational activities. This includes preparing educational materials for various types of sessions.
* Works with leaders in the implementation of Billing Compliance program initiatives, relevant guidelines and policies, identified corrective action, and any relevant regulatory change management processes/changes. This Includes participating on workgroups, project teams, tracking milestones of implementation and development, research, or engagement of required educational needs assessment.
* Assists with internal monitoring and preparation of compliance reporting to present to Senior Compliance Leadership. Prepares initial drafts of various reports to senior management, including, but not limited to reports to the CHST governance group (ex. Board of Directors). Prepares materials/handouts for various Corporate Compliance workgroups or meetings.
* Provides support to ensure that all billing compliance regulatory information is accurately communicated to our the CHST internal customers and stakeholders.
* Supports Corporate Compliance program efforts and initiatives, by maintaining, and documenting in key program tools, workflows, reporting efforts, and other program activities. These tools and platforms include, but are not limited to: Reporting Incident Management, Conflicts of Interest reporting, Business Gifts and Courtesies, Training, Regulatory Navigator, Revenue Risk Manager, the Corporate Compliance hotline and SafeLink systems.
* Coordinates with contractors, vendors, and delegated entities to provide assistance on key Corporate Compliance initiatives and ensure adherence to all regulations and contractual agreements.
* Analyzes statistical data and reports to identify and determine health care compliance issues
* Able to research state (Medicaid) and Federal (CMS) regulations to respond to internal inquiries and communicate via regulatory change management process.
* Conducts retrospective coding & billing audits per internal department workplan and develops billing compliance educational activities which include preparing educational materials for various types of training sessions or offerings including required annual Compliance training.
* Assesses and recognizes self-development needs. Seeks out resources or experiences which promote professional growth and development.
WORK EXPERIENCE
* At least 3 years Relevant healthcare industry experience or equivalent experience in another highly regulated environment Required
* At least 2 years Working knowledge of compliance, auditing and monitoring techniques and standards Required
* At least 2 years Experience in Revenue Cycle or Health plan setting Preferred
* At least 1 year Experience auditing activities and interacting with auditors and government agencies Preferred
EDUCATION
* Four-year Bachelor's degree or equivalent experience Required
* Graduate or professional work or advanced degree; or equivalent experience Preferred
LICENSES AND CERTIFICATIONS
* Certification as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or nursing license (RN/BSN) (Other relevant Revenue Cycle certifications or Clinical licenses will be considered) Upon Hire Required
* Healthcare Compliance or equivalent Corporate Compliance Certification (ex. CHC, CHRC, CHPC, CHC-F, or CCEP) - at time of hire, or within 3 years of hire Upon Hire Preferred