• Abides by the standards of Ethical Coding as set forth by the American Health Information Management Association.
• Manages projects independently, prepares governmental disclosures and facilitates external audits by regulatory agencies while working with RGHS Administration and Management.
• Coordinates and conducts audits to assess compliance with payer regulations and contract obligations. Audits include, but not limited to revenue cycle (Clinical documentation, EMR work flows, registration, coding, charging, billing, payments and denials), financial statements, payments and attestations; grants, RGHS employees and contractors for governmental exclusions and payment agreements
• Interviews key staff with professionalism and respect in order to identify cause analysis of issues identified.
• Collaborates with health care professionals to discuss findings and offer advice and education as to how to improve compliance
• Develops reports reflecting audit results and reports findings to Compliance Director, RGHS Administration and management
• Develops corrective action plans with Management and assists with implementation when necessary.
• Performs follow up audits to ensure monitors are implemented and effective.
• Analyzes studies that have been prepared by government and professional associations to assess risk and opportunity for assigned departments
• Identifies compliance benchmarks for assigned areas and performs analysis for risk assessment
• Collaborates with System Directors and/or administration regularly to ensure awareness of any regulation changes impacting their departments
• Researches and assists Compliance Director, RGHS management and administration with approvals for new business growth for the system
• Approves and collaborates with system management and administration on margin improvement initiatives, often times assists or provides the training to staff involved in implementing, to ensure compliance
• Acts as Subject Matter Expert in the continued building and optimization of the systems EMR in areas of clinical documentation, work flows and impacts on the revenue cycle to ensure compliance. Performs presentations for clinicians on appropriate documentation in the EMR
• Designs and implements training to ensure compliance. Focuses include, but not limited to Fraud, Waste and Abuse, revenue cycle clinical documentation, coding, charging, billing and denial appeals for physicians, health care providers, HIM coders and other applicable RGHS employees
• Performs and manages internal investigations into reports of non compliance (fraud, waste and abuse) by RGHS employees or external sources as directed
• Interviews system management and staff with respect and professionalism
• Completes report and investigation in a timely manner
• Reports findings to Compliance Director and follows through as directed; including assisting HR with information and interviews to ensure appropriate discipline of employees
• Performs cause analysis of non compliance
• Facilitates corrective action and monitors in affected departments with management
• Performs follow up audits in timely manner to ensure compliance
• Facilitates and manages under the general direction of Compliance Director external investigations into the system by agencies such as OIG, DOJ, OMIG, FBI, Medicare and Third Party payer fraud units. Represents the system in a positive and professional manner when communicating with agencies.