The Sr. Compliance Audit Analyst has the primary responsibility of assisting the Director, Audit Services with development, implementation and operation of the medical necessity and compliance audit functions for both professional and hospital services in accordance with requirements of the Governmental entities including Centers for Medicare and Medicaid (CMS), Health Resources & Service Administration (HRSA), State agencies/programs, and the Compliance Audit Methodology. The Sr. Compliance Audit Analyst works independently under general supervision with considerable latitude for initiative and independent judgment.
In this role, the Sr. Compliance Audit Analyst will lead, provide expert technical skills, and assist with highly visible, sensitive, and multifaceted and complex compliance audit projects. He/She will investigate compliance regulations, compliant billing requirements, summarize findings, propose recommendations and determine if management action plans mitigate risks identified in the audit. The Sr. Compliance Audit Analyst will be responsible to prioritize audit projects, develop audit planning memorandums (e.g., audit methodology) audit programs, and prepare quality audit reports with limited revision. This position will interact with all levels of management and employees, external consultants and/or attorneys. This position will be responsible for triaging compliance concerns specifically surrounding regulatory-billing compliance reported to the Compliance Department.
Further, the Sr. Compliance Audit Analyst will be as assigned / prioritized to perform investigations or incident response, as needed, by the Director of Audit Services .
Bachelors Degree in Accounting, Finance, Business Administration, Nursing or a Healthcare related field (i.e. Nursing, Health Information Management, Health Information Technician) from an accredited program or Bachelors Degree acquired within one year. De-escalation training, if applicable.
Seven or more years of experience with a hospital in a progressive Internal Audit / Compliance Audit or Revenue Cycle department, or with a public accounting / consulting firm in a hospital Internal / Compliance auditing role. Also significant exposure to healthcare regulations, hospital compliance, and Medicare reimbursement concepts is required.
One or more years of supervisory experience.
Must demonstrate knowledge of medical necessity review criteria, billing compliance, and regulatory coding for eligibility of reimbursement to perform this role and ability to follow standard practices in compliance auditing.
Experienced in researching CMS, HRSA and other Federal, State & EHSs healthcare compliance regulations, criteria for billing, billing medical necessity, and hospital coding and reimbursement guidelines and regulations.
Ability to compute ratios, percent, and to draw and interpret graphs
Ability to define problems, collect data, establish facts and draw valid conclusions
Ability to effectively present information and respond to questions from supervisor and others
Ability to interpret variety of technical instructions or diagram form and deal with several abstract and concrete variables
Ability to use systematic approach to problem solving and troubleshooting
Strong project management skills, along with the ability to take initiative and work independently
High energy level, comfortable performing multifaceted projects in conjunction with day-to-day activities
Excellent interpersonal skills, ability to get along with diverse personalities
Demonstrates positive attitude, and able to interact well and collaborate with other corporate groups (such as Legal Department and Human Resources Department)
Able to work on several projects and investigations simultaneously.
Self-motivated; requires limited supervision
Ability to lead and perform special projects
Ability to work on multiple projects and achieve deadlines
Proficiency in Microsoft Word, Excel, Access, Visio and PowerPoint
Six or more years of experience in a progressive hospital internal audit /compliance audit department or in a healthcare medical necessity, claims audit role with a public accounting or consulting firm. Experience and exposure to healthcare compliance concepts and Medicare reimbursement principles. Experienced in compliance, regulatory adherence, and billing medical necessity, and coding auditing.
Desired experience in Hospital inpatient and outpatient coding (i.e. MS-DRG, APC, ICD-10/HCPS/CPT, etc.) and CMS reimbursement principles, claims processing and healthcare compliance and claims auditing / monitoring. Knowledge of RAT-STATS Statically Valid Random Sampling methodology.
Knowledge and experience with various electronic health records such as Epic.
Knowledge of the Epic, 3M coding suite of products, GE Centricity products, and the Seimens Invision programs.
Knowledge of Microsoft Acces, Visio, PowerPoint, data mining tools (i.e. ACL) & data analysis..
Position Requirement(s): License/Certification/Registration
At least one of the following, Current licensure to practice in the State of Tennessee, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), Certified Professional Coder - Hospital (CPC-H), Certified Coding Specialist (CCS), plus Certified Internal Auditor CIA or Certified in Healthcare Compliance (CHC) or able to obtain additional certification(s) within 12 -18 months.
The Nurse Licensure Compact will not change how to obtain or renew a Tennessee license. However, the Tennessee nursing license will be a single state license for Tennessee Residents or non-compact state residents. Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents.
Registered Nurse (RN), Certified Public Accountant (CPA), Certified Internal Auditor (CIA), Certified in Healthcare Compliance (CHC). Additional certifications of Certified Professional Coder (CPC) or Certified Coding Specialist (CCS-P).
Department Position Summary:
The employee must be able to demonstrate the knowledge and skills necessary to audit and optimally code hospital outpatient/inpatient and professional service encounters. The individual must demonstrate knowledge of the various reimbursement guidelines for outpatient encounters or the ability to research them and interpret them accurately. The individual must demonstrate the ability to be flexible as to the type of encounter to be audited and coded. The associate must demonstrate the ability to work in a self-directed team by taking and providing coding guidance and sharing in the responsibility of the team. The associate must display the ability to be self-motivated, be able to evaluate the scope of each days work, and display time management skills to accomplish the work evaluated. The associate must keep her/his licensure current by participating in continuing education. The associate must provide management with a copy of her/his certificate and copy of the yearly membership card.
Perform compliance audits as per Compliance Audit Methodology including the following:
Assist / perform development & execution of account or claims data mining queries and analysis.
Perform Statistically Valid Random Sampling (SVRS) using the RAT STAT system.
Develop compliance audit programs to regulatory or billing compliance criterial and to meet the scope and objectives identified in the audit plan and consistent with requirements of CMS or other federal or state programs;
Research and apply appropriate Federal, State, and EHSï¿½s regulatory, medical necessity, billing or coding criterial to perform specific audit.
Assist and/or perform review of audit results to determine the completeness and accuracy of work papers to support audit procedures performed and results, application of Federal, State, and EHSs regulatory reimbursement guidelines including determination of Medical Necessity as per MCG or InterQual guidelines and/or other regulatory guidance documents or guidelines related to the medical necessity of patient stays.
Identify and communicate with relevant EHS resources as required to perform audit.
Prepare draft audit report.
Ensure corrective actions recommended are timely, practical and relevant.
Follow-up on status of outstanding action plans.
Perform other Compliance assignments as assigned.
Quantity = Perform assignments within budgeted resources allocated per project. Claims coding audit should be performed at an average of 2-3 claims / hour for inpatient claims. A 50 claim sample audit (Outpatient or Inpatient) should be completed within 1-2 weeks, depending on the audit complexity and criteria.
Quality = Perform assignments with proficiency and due professional care. Claims audit should be performed at a 98% accuracy.
Timeliness = Complete assignments within timelines and risk priorities defined.
Erlanger Medical Center