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Signature Healthcare is Southeastern Massachusetts’ premier local provider of quality, personalized medical services. We are comprised of the award-winning not-for-profit Signature Healthcare Brockton Hospital; Signature Medical Group (SMG), a multi-specialty physician group of more than 150 physicians practicing in 18 ambulatory locations. We believe our distinctive Signature Healthcare team approach is the way healthcare should be: medical professionals across many locations communicating and collaborating, taking advantage of technologies and resources to make a difference in the lives and health of our patients. Position Summary: The Healthcare Compliance Auditor (HCA) is a member of the Compliance Department and reports to the Chief Compliance Officer. This position is responsible for assisting the Chief Compliance Officer (CCO) with institutional compliance auditing, coding and billing audits and compliance program planning and execution. The HCA performs compliance audits, coding and billing audits and serves as a resource to Signature Healthcare (SHC) on issues related to professional and institutional coding and billing, and general corporate compliance practices. KEY RESPONSIBILITIES:
Reporting to the Chief Compliance Officer, the Healthcare Compliance Auditor contributes to the identification and reduction of SHC’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 SHC’s current billing and coding practices, validates compliance with state and federal regulations and 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 the CCO and Revenue Cycle. Management on a timely basis. The Auditor provides expert compliance advice and education to coding personnel, clinical staff and physicians, along with department and practice management
Performs audits of HCPCS, CPT coding, DRG coding, and medical record reviews using scientific methods, statistical processes and proven healthcare audit methodology with a focus on governmental payers, including Medicare and Medicaid.
The Auditor will coordinate with clinical operations, health information management and revenue cycle departments to ensure accounts audited reflect proper documentation, charge capture, coding, billing and payment.
In a timely manner, clearly communicates audit findings with providers, the department managers and identify areas of educational opportunities or required corrective actions based on audit results. Exhibits clear concise report writing and presentation skills. Conducts follow up education and develops corrective action plans to address audit findings and/or identified risks.
Responsible for performing risk assessments to identify compliance and non-compliance concerns. Assists Revenue Cycle departments with identifying risks and communicates the results to management.
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.
Conducts education of new providers on compliance, billing and documentation guidelines, fraud and abuse statutes, and the audit process.
Responds to compliance queries by clinical and non-clinical providers and staff. Maintains appropriate degree of confidentiality.
Maintains up-to-date knowledge of industry coding, billing and documentation guidelines and healthcare compliance regulations to ensure SHC system-wide consistency and compliance with governmental and other regulatory guidelines.
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 SHC’s compliance, audit and revenue objectives and goals.
Collaborates with other audits and duties as requested.
Performs other duties as assigned.
Required Knowledge and Skills:
Ability to solve practical problems and be effective in situations with limited standardization.
Ability to interpret a variety of instructions conveyed in written, oral, diagram, or other formats.
Must be able to use appropriate judgment in communications and actions with patients, physicians, other associates, outside agencies, and vendors.
Working knowledge of MS Office (i.e. Excel, Word and PowerPoint). Ability to present a variety of information to a diverse audience.
Ability to effectively interact with physicians and midlevel providers, and communicate clearly the English language, both verbally and in writing.
Education/Experience:
Education: BA or BS degree is required, commensurate with experience.
Experience (Type & Length): 3 years of coding compliance/audit experience in a health care environment; Healthcare compliance audit experience required.
Certification/Licensure: One of the following certificates is required: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Registered Health Information Administrator (RHIA )
Software/Hardware: Working knowledge of Electronic Medical Records, Word, and Excel
Other: Experience with Wolters Kluwer or Symplr Compliance platform a plus. To perform this job successfully, an individual must be able to meet expectations relative to the purpose of the position and perform each primary responsibility satisfactorily. The requirements listed herein are representative of the knowledge, skill, education, experience, and/or ability to perform this position successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the primary responsibilities.
