This paragraph summarizes the general nature, level and purpose of the job.
Compliance Hospital Billing Integrity Auditors conduct Compliance Department audits to determine organizational integrity of billing facility and technical hospital fees, including detection and correction of documentation, coding and billing errors and/or medical necessity of services billed. Audits consist of evaluation of the adequacy and accuracy of documentation in support of services billed, including ICD/CPT/HCPCS and other third party payor codes, DRG assignment, APC code assignment, medical necessity of services, reimbursement overpayments and underpayments, and compliance with other documentation, coding and billing standards.
Compliance Hospital Billing Integrity Auditors evaluate the adequacy and effectiveness of internal and operational controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and guidelines related to facility and technical fee documentation, coding and billing, including federal and state regulations and guidelines, CMS and other third party payor billing rules, and OIG compliance standards.
Compliance Hospital Billing Integrity Auditors apply standardized audit scoring methodology to consistently evaluate documentation and coding, and standardized audit findings methodology to report audit results. Compliance Hospital Billing Integrity Auditors communicate audit results to hospital service departments and departmental leadership, HIMS leadership, physicians, physician leadership, senior hospital management, coders, billers and other appropriate staff, provide physician and coder education and make recommendations for management corrective action.
Compliance Hospital Billing Integrity Auditors serve as institutional subject matter experts and authoritative resources on interpretation and application of documentation and coding rules and regulations, medical necessity of services delivered, and conduct enterprise risk assessments of potential and detected compliance deficiencies.
CAREER LADDER: Three (3) career banded levels are defined within this job family. Positions are flexibly staffed at any of the three levels and progression from one level to the next higher level depends, first, on the need for a position at the higher level; second on the nature, scope and complexity of the duties assigned; and third, on an employee's demonstrated and applied knowledge, skills and abilities and professional behaviors.
Essential Functions The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patients rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings. Must perform all duties and responsibilities in accordance with the Service Standards of the Hospital(s).
Contributes to the achievement of Compliance Department goals and objectives and adheres to departmental policies, procedures and standards; complies with governmental and accreditation regulations.
Effectively maintains collaborative working relationships with HIMS staff, PFS staff, hospital service department administrators, HIMS leadership, faculty, physician leadership, hospital management and staff to achieve increased satisfaction with and participation in the Compliance Program.
Performs scheduled and unscheduled independent Compliance Department audits of facility and technical fee documentation, coding and medical necessity related to inpatient and outpatient billing.
Conducts routine retrospective and prospective facility and technical fee audits, specialized and focused audits, and other audits as directed by the Hospital Billing Integrity Manager and Director.
Evaluates the appropriateness and medical necessity of services and procedures billed based on supporting documentation; evaluates appropriateness of ICD, HCPCS and CPT codes, evaluates the appropriateness of APC, DRG and admission assignments; evaluates appropriateness of modifier usage; makes determinations of overpayments and underpayments and performs other related analysis and evaluations.
Adheres to the defined audit timeline and audit protocol standards; assists with development of the audit schedule; identifies services to be audited.
Applies consistent and standardized compliance audit methodology for sample selection, scoring and benchmarking, development and reporting of findings and repayment calculations.
Prepares written reports of audit findings and recommendations and presents to HIMS staff, PFS staff, hospital service department administrators and management, physicians, coders, billing staff, and others as appropriate; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records.
Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities, ICD, APC and DRG utilization patterns, national normative data, CMS and PEPPER initiatives, OIG work plans and advisories, and healthcare industry best practices.
Researches, abstracts and communicates federal, state and payor documentation, billing and coding rules and regulations; stays current with Medicare, Medi-Cal and other third party rules and regulations, DRG, ICD, APC and CPT coding updates, Coding Clinic Guidelines; serves as institutional subject matter expert and authoritative resource in these areas.
Authors newsletter articles, FAQs, email alerts and other communication and educational materials; responds to informational inquiries from physicians, providers, coders, billers, management and staff regarding documentation, coding, billing and other related compliance matters.
Develops compliance training content; provides one-on-one and group training to HIMS staff, PFS staff hospital service department staff, physicians, clinicians, billing and coding staff, Compliance Department team members and others to ensure compliance with federal and state regulations and laws, CMS and other third party payor billing rules, and internal documentation, coding and billing policies and procedures; assists HIMS, PFS and other departments in evaluation of documentation, coding and billing processes and practices.
Assists in identifying areas of enterprise compliance risk and aids in resolution as needed; attends Compliance meetings as needed.
Assists departmental management with charge capture process and electronic medical record functionality and makes recommendations for improvement; assists departmental management with the development of documentation and coding tools and templates and makes documentation, coding and billing process improvement recommendations.
Assists Compliance Department management with federal, state and other special investigations and audits.
Participates in the development of the Compliance Department's long-term and short-term goals, objectives plans, policies and procedures; functions as audit team member and works on joint projects; maintains an effective working relationship with Compliance Department staff.
Annually identifies specific needs for self-development and implements a plan to achieve professional growth.
Maintains privacy of patient information and confidentiality of compliance information and activities; consistently demonstrates a high level of professionalism by exercising behaviors consistent with the Compliance Department's Guiding Principles, including but not limited to Integrity and Openness, Respect and Loyalty, Responsibility and Accountability, Balance and Control, Participation and Enthusiasm, and Humor and Fun.
All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status or on the basis of disability.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Compliance Auditor I
Education and Experience: High School Diploma or GED equivalent AND minimum of two (2) years of experience in facility fee auditing/coding or medical necessity reviews or related work.
Licenses and Certifications: Within six (6) months of employment, as a condition of continued employment, employee must obtain Certification as a Certified Coding Specialist (CCS) by the American Health Information Management Association (AHIMA) Or RN license AND minimum two (2) years experience conducting medical necessity defense reviews.
Preferred Qualifications: Current CCS or COC (formerly CPC-H) certification;Hospital Fee auditing experience in an Academic Medical Center; Experience navigating in electronic medical records; Bachelor's degree in a healthcare-related field from an accredited college or university; Certification in Healthcare Compliance (CHC) by the Healthcare Compliance Association (HCCA).
Compliance Auditor II
In addition to the minimum educational qualification as specified in level I:
Education and Experience: A minimum of two (2) years of progressive experience comparable to that of a Compliance Auditor I AND demonstrated competency in knowledge, interpretation and application of documentation, coding and billing rules or medical necessity defense strategies sufficient to carry out the duties and responsibilities of a Compliance Auditor II, including but not limited to meeting standards related to audit productivity, audit accuracy rate, timeliness of assignments, education/presentation competencies and professionalism.
Licenses and Certifications: CCS or COC (formerly CPC-H) certification required, or a RN license with a minimum of three years experience conducting medical necessity defense reviews.
Preferred Qualifications: As specified in Compliance Auditor I, with the exception that CCS or COC (formerly CPC-H) certification OR RN license with three (3) years experience as a medical necessity auditor is required.
Compliance Auditor III
In addition to the minimum educational qualification as specified in level I:
Education and Experience: A minimum of two (2) years of experience comparable to that of a Compliance Auditor II AND demonstrated competency in knowledge, interpretation and application of documentation, coding and billing rules or medical necessity defense strategies sufficient to carry out the duties and responsibilities of a Compliance Auditor III, including but not limited to meeting standards related to audit productivity, audit accuracy rate, timeliness of assignments, education/presentation competencies and professionalism.
Licenses and Certifications: CCS or COC (formerly CPC-H) certification required or a RN license with a minimum of four (4) years experience conducting medical necessity defense reviews.
Preferred Qualifications: As specified in Compliance Auditor I, with the exception that CCS or COC (formerly CPC-H) certification OR RN license with four (4) years experience as a medical necessity auditor is required.
Knowledge, Skills, and Abilities
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification. Knowledge of:
Medicare and Medi-Cal documentation and coding rules and guidelines or medical necessity defense reviews;
ICD/CPT/HCPCS/DRG/APC documentation and coding rules;
facility fee charge capture and reimbursement methodologies;
MS-DRG application; medical terminology;
healthcare compliance audit methodologies, principles and techniques;
CMS manuals, medical necessity guidelines, reimbursement and repayment principles, confidentiality standards.
interpret and apply documentation and coding rules and regulations, facility fee charge capture and reimbursement methodologies;
plan, organize and conduct healthcare compliance audits;
work cooperatively with hospital administrators, service providers, and others;
work independently, exercise sound judgment, manage diverse and conflicting priorities and projects in an effective manner, and meet deadlines;
conduct detailed compliance audits, reach independent decisions and logical conclusions, and prepare reports of findings;
maintain competence in and up-to-date knowledge of healthcare compliance requirements, practices and trends;
interpret medical record progress notes, handwritten and electronic chart entries, provider orders and other related documentation;
maintain confidentiality of compliance information and activities;
proficiency in the use of personal computers with Windows operating systems, including the Microsoft Office applications such as MS Word, Excel, Outlook and PowerPoint;
communicate effectively, both orally and in writing.