Senior Auditor - Internal Audit Financial Crimes & Compliance Issues Management, Vice President

Summary The Clinical Compliance Auditor plans, schedules, and performs comprehensive internal professional fee audits to include routine audits, focused audits, for cause audits, and not for cause audits for Chesapeake Regional Healthcare (CRH) and all of its affiliated entities. Performs detection of documentation, coding, and billing errors as well as collaboration with appropriate stakeholders to ensure corrective action and/or appropriate response to identified issues. Communicates audit results to providers, coders, management, and other appropriate staff. Develops and delivers provider and coder education. Evaluates the effectiveness of internal controls designed to ensure that processes and practices lead to regulatory compliance with guidelines related to medical necessity, and professional fee documentation, coding, and billing. Stays abreast of medical necessity documentation, coding, and billing regulations and standards and serves as a subject matter expert on the interpretation and application of medical necessity documentation, along with coding rules and regulations.Essential Duties and ResponsibilitiesThese duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned. Essential functions may include, but are not limited to, the functions listed below:• Plans, schedules, and performs comprehensive internal professional and hospital fee audits as determined by the Compliance Work Plan to include routine and focused audits.• Detection of documentation, coding, and billing errors as well as collaboration with appropriate stakeholders to ensure corrective action and/or appropriate responses are implemented to address identified issues.• Communicates audit results to providers, coders, management, and other appropriate staff and makes recommendations to ensure sustained compliance and improvement.• Develops and delivers provider and coder education, as needed.• Evaluates the effectiveness of internal controls designed to ensure that processes and practices lead to regulatory compliance with guidelines related to professional and hospital fee documentation, medical necessity, coding, and billing, including federal and state regulations, CMS, and OIG compliance standards.• Able to determine medical necessity on the basis of the individual case and taking into account: type, frequency, extent, body site, and duration of treatment with scientifically based on CMS guidelines and guidelines of national medical or health care coverage organizations and/or governmental agencies.• Stays abreast of ever-changing medical necessity documentation, coding, and billing regulations and standards.• Serves as subject matter expert on interpretation and application of documentation and coding rules and regulations.• Develops compliance auditing plans based on thorough research on studies conducted by government agencies and professional organizations.• Compiles reports on the results of external and internal audits and presents these reports to the relevant supervisors and department heads.• Performs audits according to the established Compliance Work Plan and calendar and prepares Compliance Work Plan summary slides with appropriate corrective action plans.• Assists with the modification of the Compliance Work Plan calendar through the year to include additional audits, based on audit results, risks, and corrective action plans.• Assists the Compliance Committee and presents summary of audit activities to the committee.• Provides results of audits and education to HIM, Revenue Cycle Departments, physicians, hospital and clinic operations regarding charging, documentation, and billing requirements.• Assists departments with development of corrective action plans (CAPs), as needed, and ensures CAPs are implemented and evaluated for effectiveness by performing follow up audits/reviews in a timely manner.• Communicates effectively with the Corporate Compliance team and CRH and its affiliated entities following the CRH Code of Conduct.• Performs medical record audits of documentation, coding and billing for technical and professional services, including: CPT; ICD10; HCPCII; DRG; APC; APG; Modifiers; Non-Physician Practitioner Documentation (including “incident-to” guidelines), and other services;• Conducts audits of electronic and manual documentation, coding, and billing systems.• Develops formal audit reports of findings and recommendations, which are presented to senior management of applicable department, the Corporate Compliance Committee and Operations Quality and Safety Committee.• Participates in external government audits, including but not limited to: Centers for Medicare and Medicaid Services (CMS); Office of Inspector General (OIG); Medicaid Fraud Control Unit (MFCU); Virginia Department of Health (DOH); Medicaid Integrity Program Contractor (MIC); Recovery Audit Contractor (RAC); Zone Program Integrity Contractor (ZPIC); Health Care Fraud Prevention and Enforcement Action Team (HEAT)• Participates in development of voluntary disclosures and repayments to federal and state agencies.• Conducts opening and closing meetings with senior management of applicable department being audited.• Identifies compliance risk areas and develops action plans accordingly.• Develops and coordinates analysis of encounter forms and documentation templates.• Audits and enforces compliance policies and procedures.• Develops and conducts documentation, coding and billing curriculum and education classes for more than 100 physicians, allied health professionals, and coding and billing associates annually.• Assists in development of risk areas and audit creation.• Assists with distribution of all Medicare and Virginia Department of Health updates and code changes to the appropriate associates.• Facilitates responses to compliance-related inquiries (phone, e-mail, in-person)• Responsible for other matters as assigned by the Chief Corporate Compliance Officer and/or Compliance Manager.Candidate Attributes: The ideal candidate will:• Pay close attention to detail and strive for excellence.• Possess curiosity for learning CRH’s business, products and solutions.• Thrive in a dynamic environment by practicing effective time management and prioritization of tasks.• Comfortable in making recommendations in compliance, audit, and contractual matters.• Effectively assist cross-functional projects to completion.• Display strong communication and writing skills.• Display excellent judgment and strong organizational skills• Possess a willingness and ability to work and coordinate activities across a large number of individuals in various departments.• Ability to pass required background checks and clearances.Supplemental Instructions• Conduct special projects as assigned.• Perform other job-related duties as necessary or assigned.QualificationsTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to pass required background checks and clearances.Education and Experience• Registered Nurse• Experience as a coder in a hospital and/or healthcare environment• Extensive knowledge of evaluation and management coding, modifiers, provider-based billing, and auditing principles• American Academy of Professional Coders (AAPC) coding certification (such as Certified Professional Coder (CPC) or dual CPC and Certified Professional Biller (CPB))• An in-depth understanding of the industry's rules, guidelines, and regulations.• Strong attention to detail, analytical, and statistical skills.• Strong communication and multitasking skills.• Dedication to objectivity.• Experience in healthcare revenue cycle, auditing, clinical operations and/or compliance preferred.• Knowledge of DRG, CPT, CDM and billing operations• Knowledge of hospital department operations.• Knowledge of and experience with EPIC and Athena electronic medical records• Strong Skills with Microsoft products (Excel, Word, and Power Point)• Strong verbal and written communication skillsPreferred• Three (3) years auditing experience in a hospital and/or healthcare environment• Bachelor’s degree in Nursing, Healthcare Administration, Business, and/or Accounting• Auditing certification such as Certified Professional Medical Auditor (CPMA) or other accredited auditing certification• Health Care Compliance Association (HCCA) membership and certificationPI245309389