Description

Job Summary

Responsible for the oversight and management of coding and documentation auditing activities (for professional & facility services), policies and procedures, risk assessments, and development of written guidance to disseminate to clinicians and/or operational leaders. Supports the health system in ensuring compliance with federal/state laws and regulations, and Nicklaus Children's policies. Responsibility involves the management of three (3) billing compliance personnel, workflow analysis, productivity, auditing, quality review, problem resolution, and supervision.

Job Specific Duties

• Oversee and supervise billing compliance team, including work allocation, production expectations, training, and quality of work performance.
  
• Manage the billing compliance audit program; develop, organize, track, and analyze audits performed by the team.  
  
• Create audit schedules and manage workflows to adhere to the audit schedule. 
  
• Develop methods to effectively communicate audit findings through presentations, graphs, reports, etc.
  
• Develop, establish, and review policies and objectives consistent with those of the organization to ensure efficient departmental operations. 
  
• Conduct Pro Fee and DRG validation (clinical/coding) audits to determine accuracy of billing through verification of coding and supporting clinical documentation.  
  
• Consult and seek guidance and direction from the compliance director. 
  
• Serve as a point of contact for reports of billing compliance concerns or potential issues. Respond timely and professionally.  
  
• Investigate billing compliance matters at the direction of the Compliance Director and/or Chief Compliance Officer. 
  
• Conduct and/or manage special projects to include ad hoc audits, government and payer audit investigations and queries. 
  
• Maintain current knowledge of changes in federal and state coding and billing regulations/guidelines and ensure staff is kept informed. 
  
• Perform special or ad hoc audits and other duties as assigned. 
  
• Perform evaluation of the audits and recommend new standards and reports to be utilized in the audit process.

Qualifications

Minimum Job Requirements

• Bachelor's Degree Healthcare Administration, Business, related field (or) 4-7 years of equivalent work experience
  
• Certified Coder Coding certifications - CPC, CCS, CPMA
  
• Cert in Healthcare Compliance Compliance Certificate - CHC within 1 year of hire
  
• 4-7 years of experienced in billing compliance, medical coding, or other relevant experience
  
• 4-7 years of supervisor experience
  
• 3-5 years of audit experience

Knowledge, Skills, and Abilities

• Thorough knowledge and understanding of diagnosis-related group (DRGs) and overall hospital billing, coding, and documentation.
  
• Knowledge and understanding of Centers for Medicare and Medicaid Services (CMS) guidelines.
  
• Ability to maintain highest level of confidentiality.
  
• Ability to follow-through, meet regulatory deadlines, and anticipate.
  
• Ability to lead in a team environment with minimal supervision.
  
• Strong analytical and problem-solving skills.
  
• Excellent time management and organization skills.
  
• Able to use considerable use of tact, diplomacy, discretion, and judgment.
  
• Systems knowledge of Cerner.
  
• Effective presentation skills.
  
• Knowledge of Federal and State regulations related to healthcare billing compliance.
  
• Certified Inpatient Coder (CIC) Certificate.

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