Leads advanced, complex compliance audits and investigations with a primary focus on revenue cycle by reviewing medical records for documentation compliance for CPT, Level II HCPCS, and diagnosis codes determining that regulations are being complied with as evidenced in medical record documentation; and evaluating appropriateness of billing and coding procedures. Requires advanced knowledge of CPT, Level II HCPCS, diagnosis coding, and government payer regulations. Work involves actively directing and conducting compliance audits, investigations, corrective action plans, regulation research, organizational education, and proving consultative services to the organizations senior leadership, providers and staff; advising and assisting on the development of the Corporate Compliance annual audit work plan, awareness and mitigation of revenue cycle risks; and providing training and coaching to staff. Assists and advises Corporate Compliance Auditors with their audits, projects and investigations. Possesses data analytic and presentation skills. Maintains and promotes all organizational and professional ethical standards. Considered a high level contributor and viewed as an expert internally.
Independently completes assignments, manages audits and projects, performs regulatory research, investigations, participating and collaborating 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 wide cross-section of executive leaders, directors, managers, providers and front line staff to fulfill job requirements.
Works with minimal direction.
Strong negotiating skills and ability to tactfully resolve problems.
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.
Leads investigations, interviews, reviews documents, and documents key issues and ability to communicate results effectively to front-line staff to senior leaders.
Skill in conducting quality and thorough audits and reviews by using strong critical thinking skills, operational workflow knowledge, ability to research, as well as negotiating skills.
Evaluate practice patterns, data-mining, analyzing 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 solve and assess potential risks identified, prioritize concerns, and provide educational needs to various skill levels, such as physician, ancillary, nursing, coding and billing staff.
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 for all Fairview by staying up-to-date with local, state, federal laws, regulations and guidelines, as well as monitoring payer bulletins, periodicals and web-sites to maintain revenue cycle knowledge.
Effectively work with and coordinate the activities of external consultants and legal counsel as assigned.
Excellent written and oral communication and presentation skills a must.
Team player who has strong negotiating skills and ability to tactfully resolve problems.
Oversees and evaluates orientation and onboarding of corporate compliance auditors. May provide input in the review and evaluation of corporate compliance auditors performance.
Leads and works on task forces and committees representing compliance.
Assist in developing of audit templates and procedures.
Bachelors Degree in Health Information Management, Nursing, business administration, healthcare administration or related field
10 years Active Coding experience
2 years experience with auditing concepts and principles
Knowledge of proper documentation of medical services and the electronic health record
Registered Health Information Administrator (RHIA),
Registered Health Information Technician (RHIT)
Certification through AAPC or AHIMA
Masters Degree in Health Information Management, Nursing, business administration, healthcare administration or related field
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.