SUMMARY

The Healthcare Compliance Auditor would be responsible for providing assurance through audits and recommendations that adequate procedures and processes exist to ensure professional billing and coding is complete and accurate. This position will also be responsible for performing risk assessments to identify compliance and non-compliance concerns. The Healthcare Compliance Auditor will coordinate with clinical operations, revenue cycle departments to ensure accounts audited reflect proper documentation, charge capture, coding, billing and payment. As part of the Compliance department, the position is also responsible for educating and promoting compliance with all policies and guidelines throughout the organization.

ROLE RESPONSIBILITIES

Reporting to the Assistant Manager of Corporate Compliance of Connecticut Children's, the Healthcare Compliance Auditor contributes to the identification and reduction of CCMC's coding compliance risks, billing inaccuracies, and/or denials by coordinating independent reviews and assessments of the organization's professional coding and billing transactions, processes, and internal controls for coding completeness and accuracy. The Healthcare Compliance Auditor evaluates the effectiveness of current billing and coding internal controls; validates compliance with state and federal regulations, internal policy and procedure mandates; and recommends process, procedure, and policy improvements to mitigate against identified risks. This position is responsible for identifying potential coding and billing errors, researching appropriate guidelines to support recommended improvements, and communicating these improvements to Revenue Cycle Management on a timely basis. The Healthcare Compliance Auditor provides expert compliance advice and education to coding personnel, clinical staff and physicians, along with department and practice management.

Position Specific Role Responsibilities

• Coordinates and executes pre- and post-payment audits of medical records and associated clinical documentation to ensure proper charge capture and billing in accordance with standard state, federal, and internal reimbursement policies, principles, and mandates.
  
  • Assists revenue cycle departments with identifying risks and communicates the results to management
  • With the Assistant Manager, develops and executes the yearly objectives for the department.
  • Performs education of new providers to compliance, fraud, and abuse statutes, and the audit process
  • Responds to compliance queries put forth by clinical and non-clinical providers and staff.
  • Maintains up-to-date knowledge of industry coding, billing and documentation guidelines so as to ensure system-wide consistency and compliance with governmental and other regulatory guidelines.
  • Maintains up-to-date knowledge of healthcare compliance regulations so as to ensure system-wide consistency and compliance with governmental and other regulatory guidelines.
  • Communicates audit findings with auditees in a timely manner.
  • Communicates audit findings with the departmental management and identifies areas of educational need based on audit results.
  • Maintains an open dialogue and good working relationship with external auditors, Revenue Cycle, HIM, and Coding Management; and clinic/department staff and their leadership in order to advance CCSG and CCMC revenue objectives and goals.
  • Responsible for timely completion of Revenue Cycle Compliance projects and processes
  • Assists with training of new auditors.
  • Collaborates with other audits and duties as requested.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

Human relations and excellent written and verbal communication skills are essential. Strong analytical skills, with extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and billing, with demonstrated ability to interpret such guidelines.
Demonstrates an advanced knowledge and skill in analyzing patient records to identify non-conformances. Proficient in the use of word processing and spreadsheet software, Word and Excel. Excellent interviewing and report writing skills. Ability to quickly identify risk, its likelihood and possible impact, root cause, and make recommendations for risk mitigation. Assumes working knowledge in the field of health care, revenue reporting and/or reimbursement. Demonstrates ability to lead groups and work on numerous projects simultaneously.

Work Environment:

Clinical and Non-clinical work environment.