Overview:
The Compliance Specialist is responsible for performing audits and reviews of health information records specific to coding, billing and documentation compliance issues and providing educational in-services relative to audit findings.
Responsibilities:
Performs audit engagements to ARH facilities for the purpose of reviewing, assessing the billing, coding, and documentation practices and to identify areas of risk.
Provides educational in-services tailored to address identified areas of risk in billing and documentation.
Reviews the medical records of Medicare patients, specifically, to insure the accuracy of the physician’s assignment of principal diagnosis, complications, co-morbidity’s, and procedures (documentation) that impact hospital reimbursement. Reviews other payer classes as required
Audits the accuracy of the assigned ICD-9-CM codes, CPT-4 codes and DRG, as appropriate. Performs Case Mix Index (CMI) Analysis as deemed necessary.
Prepares written reports to communicate audit findings and recommendations and participates in the exit conference.
Keeps abreast of any new developments and changes in OIG,Federal and State regulations as they relate to billing, coding and compliance issues.
May assist in other auditing functions and perform other related duties as assigned.
Qualifications:
EDUCATION, TRAINING, AND EXPERIENCE:
Two year college degree (minimum) and successful completion of the examination for Registered Health Information Technician (RHIT), Registered Health information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Procedural Coder-hospital (CPH-H), Certified Procedural Coder (CPC), or Certified Specialist-Physician Based (CCS-P) or equivalent.
Two (2) years experience in coding. Working knowledge of ICD-9-CM coding, CPT-4 coding and PPS systems PLUS excellent communication and writing skills required.
Will be required to travel (60%).
POSITION PHYSICAL REQUIREMENTS:
Must possess physical ability to endure prolonged sitting; moderate walking; lifting and carrying. May require exerting up to 20 pounds of force occasionally; and/or up to 10 pounds of force frequently; and/or a negligible amount of force constantly to move objects. Physical Demand requirements are in excess of those for sedentary work.
SPECIFIC ACCOUNTABILITIES:
Accountable for performing engagement audits focused on identifying billing, coding and documentation compliance issues and opportunities for improvement.
Accountable for providing an educational resource and providing focused education and training to meet needs identified.
Accountable for the direct review of medical records to facilitate improvement in the overall management of health information, and ultimately expedite the coding and reimbursement process.
Accountable for the review of OIG Work Plan and plan of education to facilitate within the communities
Accountable for communicating results of reviews to appropriate parties and acting as a resource to promote improvement.
