Performs compliance audits and investigations with a primary focus on revenue cycle by reviewing medical records for documentation compliance for CPT, Level II HCPCS, diagnosis codes, and claims to determine compliance with regulations as evidenced in medical record documentation; and evaluating appropriateness of billing and coding procedures. Requires knowledge of CPT, Level II HCPCS, diagnosis coding, claims review, and government payer regulations. Work involves actively directing and conducting compliance audits, investigations, corrective action plans, regulatory research, workforce education, and providing consultative services to the organizations senior leadership, providers and staff; providing key contributions to the development of the Corporate Compliance annual audit work plan, awareness and mitigation of revenue cycle risks; and providing training and coaching to staff. Maintains and promotes all organizational and professional ethical standards. Works autonomously under general supervision with considerable latitude for initiative and independent judgement.
Independently completes assignments, manages audits and projects, performs regulatory research, investigations, participates and collaborates in the claims review process, providing documentation and compliance educational sessions to senior leadership, clinical staff, providers, revenue cycle leadership and staff, auditing and monitoring the quality and data integrity of Fairviews coding, documentation and billing practices.
Communicates and interacts with a wide cross-section of executive leaders, directors, managers, providers and front-line workforce to fulfill job requirements.
Ability to define audits, identify potential risk areas, create transparency with operations, understand operational workflows, develop appropriate action plans, document findings, draft reports and communicate results to leadership (within minimal oversight).
Liaise with Operations to ensure audit findings are remediated and action plans are sustained and to identify emerging risks.
Apply judgment to ensure compliance with coding, documentation, and billing laws, regulations and guidelines that govern Fairview Health Services to safeguard, protect and disclose against fraud, waste and abuse while receiving appropriate reimbursement for the care provided.
Conducts investigations, interviews, reviews documents, and summarizes and documents key issues and ability to communicate results effectively to front-line workforce to senior leaders.
Skill in conducting audits and reviews by using strong critical thinking skills, operational workflow knowledge, ability to research, as well as negotiation skills.
Evaluate practice patterns, data-mining, analyze and present oral and written conclusions to leadership and departments in applying and improving compliance and internal controls.
Provide on-going monitoring, as needed.
Excellent ability to sustain focus and attention to detail.
Strong ability to problem solves and assess potential risks identified, prioritize concerns, and provide educational needs to various skill levels, such as physician, ancillary, nursing, coding and billing workforce.
Considerable knowledge of and skill in applying and educating on federal and state rules and regulations, coding and billing principles and practices (i.e. AHIMA, AMA, Federal Register, CMS, OIG).
Act as a resource for documentation, coding, claim review process, and billing questions by staying current with local, state, federal laws, regulations and guidelines, as well as monitoring payer bulletins, periodicals and websites to maintain revenue cycle knowledge.
Effectively work with and coordinate the activities of external consultants and legal counsel as assigned.
Advanced written and oral communication and presentation skills a must.
Participates on committees representing compliance.
Bachelors Degree or 5 years of coding or auditing experience
5 years of coding or auditing experience
Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT), Coding Certification through the AAPC or AHIMA
2 Years Compliance Auditing Experience.
Data analytics software experience.
Experience navigating an Electronic Medical Record System.
Together with the University of Minnesota and University of Minnesota Physicians we have created M Health Fairview. M Health Fairview is the newly expanded collaboration among the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. The healthcare system combines the best of academic and community medicine — expanding access to world-class, breakthrough care through our 10 hospitals and 60 clinics.Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 10 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area.Its broad continuum also includes 60 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider network and health insurer PreferredOne. In partnership with the University of Minnesota, ...Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.