Conduct health-system wide compliance audits to ensure data integrity, compliance with federal and state regulations pertaining to but not limited to: federal healthcare program requirements, coding and documentation and clinical trials billing. Interpretation of applicable federal and state law & regulations to plan audit parameters, determine department's compliance with such regulations and communicate to department necessary changes in compliance with regulatory requirements. As well as, manage health system wide response to governmental audits to ensure data integrity and completeness of records and accuracy of claims.
Duties and Responsibilities of this Level:
- Responsible for conducting compliance audits, documenting & communicating findings and recommendations, explaining regulatory requirements, and overseeing the corrective actions for audits within DUHS
- Manage activities related to monitoring requests and responses of governmental audits (e.g. RAC and Medicaid Program Integrity), monitor and trend activity, and oversee and monitor appeals.
- Conduct risk assessments and preparation of work plans.
- Develop an understanding of the operations, system processes and procedures used in areas being audited.
- Review and test for compliance with institutional policies and procedures, applicable laws and regulations through the inspection of physical operations, processes, retrieval and review of documents and investigation of irregularities and errors.
- Compile information and/or prepare reports and analyses setting forth results of compliance audits with appropriate recommendations; perform subsequent audits to ensure complete and appropriate corrective action.
- Develop recommended corrective actions to address issues detected.
- Actively participates in exit conferences, providing clarification and supporting information necessary.
- Performs other related duties incidental to work described above
Required Qualifications at this Level
Education: Work requires a general business background generally equivalent to a Bachelor's degree in a business administration, accounting, management, healthcare administration, other related degree.
Experience: Four years of experience related to legal, regulatory compliance, patient advocacy, supervisory role in patient financial services or HIM services, or other relevant experience.
Degrees, Licensure, and/or Certification: N/A
Knowledge, Skills, and Abilities: Knowledge of billing compliance, knowledge of Medicare/Medicaid regulations, including billing, coding and documentation requirements. Coding certification (e.g. CPC, CCS, RHIA, RHIT) or applicable experience is preferred.
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