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Compliance Audit Director - Remote - must be local to Nashville!!

Integrated Oncology Network

Integrated Oncology Network

Legal
Knoxville, TN, USA
Posted on Tuesday, June 11, 2024
Partnering With Physicians To Provide Best In Class Patient Care

Founded in 2002, Integrated Oncology Network is committed to helping our physicians deliver the right care, at the right time and in the right setting. We strongly believe that preserving the independent practice of medicine where patients are cared for closer to home and surrounded by our dedicated clinicians yields better outcomes. By creating a care continuum between our clinicians, patients and their support networks we deliver an unparalleled approach to the patient’s care journey.

Reporting to the VP, Compliance/Chief Compliance Officer (CCO), this position supervises and conduct audits to determine organizational integrity of billing for professional (physician) services and/or hospital (technical) services, including: detection and correction of documentation, coding, and billing errors and/or medical necessity of services billed. Particular areas of focus include: evaluation of the adequacy and accuracy of documentation in support of services billed; compliance with other documentation and coding and billing standards; communication of audit results to physicians, physician leadership, senior leadership, management, and staff; physician and coder education; and the make of recommendations for corrective action to leadership, coders, billers and other appropriate staff. This position will also support the VP/CCO with transactional audit diligence and integration planning, as well as the development and completion of the annual enterprise risk assessment and audit and monitoring plan. The Director has supervisory responsibility for the Compliance Audit Manager.

Essential Duties And Responsibilities

The following duties and responsibilities reflect the expectations of this position but are not all-inclusive:

  • Plans and performs professional compliance department audits to determine accuracy and adequacy of documentation and coding related to physician or hospital (inpatient and outpatient) billing and/or medical necessity reviews.
  • Conducts focused audits involving specific errors/issues that are identified by the RCM team or by clinic teams. Leads data analytics and the revenue cycle team in identifying the time period of review and conducts a focused audit to identify any financial liability of the Company.
  • Evaluates the appropriateness of billed services and procedures based on supporting record documentation and ensures documentation by providers conforms to legal and procedural requirements.
  • Prepares written reports of audit findings, with recommendations, and presents to appropriate stakeholders; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records.
  • Conducts risk assessments to define audit priorities based on previous audit findings, management priorities, coding utilization patterns, national normative data, CMS and CCI initiatives, OIG work plans and advisories and healthcare industry best-practices.
  • Develops and implements compliance training to ensure compliance with federal and state regulations and laws, CMS and other third-party payer billing rules and internal documentation, coding and billing policies and procedures. Conducts compliance orientation training for new providers as well as Revenue Cycle team members, as needed. Provides feedback and training for physicians and staff regarding coding insufficiencies.
  • Serves as institutional subject matter expert and authoritative resource regarding federal, state and payer documentation, billing and coding rules and regulations, maintaining awareness of governmental regulations, protocols and third-party requirements.
  • Facilitates assigning of ICD-9 and ICD-10 codes by analyzing patient medical records.
  • Availability to assist with research of denied claims.
  • Maintains a functional knowledge of enterprise EMRs, the registration process and charge entry.
  • Supports the overall workplan of the Compliance Department.
  • Other duties as assigned.

Minimum Qualifications

Education, licenses, certifications, and experience required to fulfill the essential duties, include computer skills as required.

  • Bachelor's degree in Health Information Management, Business or related field required.
  • 5+ years of experience in physician and/or hospital technical coding/auditing, medical necessity reviews, or related work.
  • AAPC or AHIMA coding certification (CPC, CCS, CCS-P, COC, or RHIA, etc.) required. Auditing certification preferred.
  • Extensive knowledge of evaluation and management and/or hospital facility fee coding and auditing.
  • Expert-level knowledge of Medicare and Medicaid documentation and coding rules and guidelines; ICD/CPT/HCPCS/DRG/APC documentation coding rules; charge capture and reimbursement methodologies; medical terminology; E/M rules, teaching physician guidelines, and/or medical necessity defense reviews; healthcare compliance audit methodology, principles and techniques; CMS manuals; professional and/or hospital services reimbursement and repayment; confidentiality standards.
  • Ability to interpret and apply documentation and coding rules, laws and regulations and to interpret medical record progress notes, handwritten and electronic chart entries, provider orders and other related documentation.
  • Strong attention to detail with an emphasis on organizational and analytical skills.
  • Understanding of institutional risks and appropriate judgment to use a risk-based approach in planning and executing duties.
  • Ability to communicate complex and potentially sensitive issues to all levels of management including senior leadership.
  • Prompt and efficient ability to manage shifting priorities, demands and time lines using analytical and problem-solving capabilities.
  • Ability to effectively prioritize and execute tasks in a fast-paced, dynamic environment.
  • Cancer service line experience preferred; ASTRO and ACR-guideline knowledge preferred.
  • Previous Revenue Cycle Operations role preferred.
  • Strong communication and presentation skills.
  • Proficiency in MS Word, Excel, PowerPoint, and Outlook.

Required Competencies

Ability to work in a team environment and perform multi-job functions. Knowledge of medical terminology and electronic medical records. Professional and/or hospital services auditing experience. Exceptional Customer Service Skills. Proven interpersonal communication skills. Excellent time management, personal integrity and ability to maintain confidentiality.

Physical Demands And Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: Required job duties are essentially sedentary in nature, consisting of occasional walking, standing, lifting and/or carrying ten pounds maximum, seeing, speaking and hearing. Must be able to lift up to 25 pounds.

Work environment: Required job duties are normally performed in a climate-controlled office environment.