Job Summary This paragraph summarizes the general nature, level and purpose of the job.
Compliance Professional Services Billing Integrity Auditors conduct Compliance Department audits to determine organizational integrity of billing for professional services, including detection and correction of documentation, coding, and billing errors.
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, Teaching Physician guidelines, medical necessity of services, reimbursement overpayments and underpayments, and compliance with other documentation, coding and billing standards.
Compliance Professional Services 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 professional 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 Professional Services Billing Integrity Auditors apply standardized audit scoring methodology to evaluate consistency of documentation and coding, and standardized audit findings methodology to report audit results. Compliance Professional Services Billing Integrity Auditors communicate audit results to physicians, physician leadership, senior hospital and School of Medicine management and staff, provide physician and coder education and make recommendations for management corrective action.
Compliance Professional Services Billing Integrity Auditors serve as institutional subject matter experts and authoritative resources on interpretation and application of documentation and coding rules and regulations, 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, abilities and professional behaviors.
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, patient 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 faculty, physician leadership, hospital and School of Medicine management and staff to achieve increased satisfaction with and participation in the Compliance Program.
• Performs scheduled and unscheduled independent Compliance Department audits of professional services billed through Stanford Hospital and Clinics, Lucile Packard Children's Hospital and other related billing numbers, including accuracy and adequacy of professional services documentation and coding related to inpatient and outpatient billing.
• Conducts routine retrospective and prospective professional fee audits, specialized and focused audits, and other audits as directed by the Professional Services Billing Integrity Manager and Director.
• Evaluates the appropriateness of services and procedures billed based on supporting documentation; evaluates appropriateness of diagnoses (ICD) and procedural (CPT) codes billed for services; evaluates adequacy of documentation to meet the Teaching Physician guidelines; evaluates level of service billed for evaluation and management (E/M) services, 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 physicians and providers 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 management, clinical chairs and chiefs, physicians, coders, billing staff, departmental management 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, coding utilization patterns, national normative data, CMS and CCI 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, CPT updates and ICD coding; 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 faculty physicians, advanced practitioners, 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 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.
CAREER BANDED LEVELS
Three career banded levels are defined within this job family denoting a progression of responsibility, knowledge, and skill requirements and experience.
•Compliance Auditor I (entry/contributing)
•Compliance Auditor II (full proficiency/journey)
•Compliance Auditor III (Advanced/Senior)
The primary distinction between levels is reflected in the Level Descriptors. As levels increase, scope, complexity, and degree of independence increase. Higher levels may perform duties of lower levels. Education, experience, licenses, and certifications are stated at the minimum threshold for the level. The distinguishing features of each level and the requirements and qualifications for placement at each level follow.
Compliance Auditor I - Professional Services Billing Integrity
Compliance Auditor I is the first working level. Performs a variety of compliance audits, special projects, and investigations. Work is limited to less complex audits. Conducts audit and provides analysis, appraisals, counsel, information and recommendations concerning activities reviewed. Evaluates compliance with applicable rules, regulations, processes, policies, and procedures. Non-routine problems/issues are referred to a higher level. Completed assignments are reviewed for conformance with standards, policies and procedures.
Compliance Auditor II - Professional Services Billing Integrity
This is the full proficiency or journey level of the Compliance Auditor job family where employees are responsible for independently performing the full range of duties of moderate difficulty and complexity as outlined under the Essential Functions. Performs audits of limited scope with greater independence. Plans, performs and provides analysis, appraisals, counsel, information and recommendations concerning activities reviewed. May be responsible for determining audit scope, procedures, and key controls. May identify problems, determine significance of, and solve problems.
Compliance Auditor III - Professional Services Billing Integrity
Compliance Auditor III is the advanced or senior level of the job family. Employees have substantial authority and responsibility for exercising independent judgment and performing all types of auditing activities as stated in the Essential Functions, including the most complex, sensitive, and controversial, which require extensive research, interpretation, and application of laws and regulations. Makes institutional determinations and provides direction to Revenue Managers, Department Financial Administrators (DFA's) in the School of Medicine, physicians and others regarding acceptable documentation, coding and billing practices, Positions at this level may be assigned primary responsibility for assigning and reviewing the work of audit teams and providing training and guidance to lower-level auditors. The typical position in this level is a Senior Auditor.
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 professional fee auditing, coding, 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 Professional Coder (CPC) by the American Academy of Professional Coders (AAPC).
• Current CPC or CCS-P certification.
• Professional Fee auditing experience in an Academic Medical Center
• Experience navigating in electronic medical records
• A 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 Compliance Auditor 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 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
CPC or CCS-P certification required.
As specified in Compliance Auditor I, with the exception that CPC or CCS-P certification is required for Compliance Auditor II.
COMPLIANCE AUDITOR III
All of the above, and, in addition:
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 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
CPC or CCS-P certification required.
As specified in Compliance Auditor I, with the exception that CPC or CCS-P certification is required for Compliance Auditor III.
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; ICD/CPT/HCPCS coding rules; teaching physician guidelines; E/M rules; medical terminology; healthcare compliance audit methodology, principles and techniques; CMS manuals; professional services reimbursement and repayment; confidentiality standards.
Ability to: interpret and apply documentation and coding rules and regulations; work cooperatively with faculty, advanced practitioners, hospital and School of Medicine administrators, revenue management, coders, 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.