Senior Compliance Auditor

City/State:

Bronx, New York

Grant Funded:

No

Department:

Compliance - Education And Audits

Work Shift:

Day

Work Days:

MON-FRI

Scheduled Hours:

8:30 AM-5 PM

Scheduled Daily Hours:

7.5 HOURS

Pay Range:

Job Summary

Safeguards Montefiore Medical Center revenue and reputation, through the following activities:
• Participates in external government audits, including:

• NY Office of Medicaid Inspector General (OMIG)
• Office of Inspector General (OIG)
• Medicaid Fraud Control Unit (MFCU)
• NY Attorney General (AG)
• NY Department of Health (DOH)
• Centers for Medicare and Medicaid Services (CMS)
• National Government Services (NGS)
• Medicaid Integrity Program Contractor (MIC)
• Recovery Audit Contractor (RAC)
• Zone Program Integrity Contractor (ZPIC)
• Health Care Fraud Prevention and Enforcement Action Team (HEAT)

• Communicates with external agencies regarding audits.
• Participates in development of voluntary disclosures and repayments to federal and state agencies.
• Coordinates, supervises, and performs medical record audits of documentation, coding and billing for technical and professional services, including:

• CPT
• ICD9
• HCPCII
• DRG
• APC
• APG
• Modifiers
• Teaching Physician Guidelines
• Non-Physician Practitioner Documentation ( including "incident-to" guidelines)

• Conducts audits of electronic and manual documentation, coding, and billing systems.
• Develops formal audit reports of findings and recommendations, which are presented to senior management of applicable department, the Executive Compliance Committee and the Board of Trustees.
• Conducts close-out meetings with senior management of applicable department.
• Coordinates audit activities with Internal Audit, as necessary.
• Identifies compliance risk areas and develops action plans accordingly.
• Develops and coordinates analysis of encounter forms and documentation templates.
• Audits and enforces compliance policies and procedures.
• Develops and conducts documentation, coding and billing curriculum and education classes for 500 + physicians, allied health professionals, and coding and billing associates annually, including:

• One-on-one education sessions based on audit findings
• Topic-specific group education
• Mandatory Compliance education
• Compliance Monthly education calendar sessions
• Grand Rounds
• Monthly Faculty Meetings

• Assists in development and distribution of MediRegs risk assessments to various departments to determine inclusion in annual work plan.
• Assists with distribution of all Medicare and DOH updates and code changes to the appropriate associates.
• Facilitates responses to compliance-related inquiries (phone, e-mail, in-person).


Essential Functions

• Participates in external government audits, including:
  * NY Office of Medicaid Inspector General (OMIG)
  * Office of Inspector General (OIG)
  * Medicaid Fraud Control Unit (MFCU)
  * NY Attorney General (AG)
  * NY Department of Health (DOH)
  * Centers for Medicare and Medicaid Services (CMS)
  * National Government Services (NGS)
  * Medicaid Integrity Program Contractor (MIC)
  * Recovery Audit Contractor (RAC)
  * Zone Program Integrity Contractor (ZPIC)
  * Health Care Fraud Prevention and Enforcement Action Team (HEAT)
  * Ensure timely and accurate response to external audit, in order to mitigate Medical Center risk (financial and reputational) imposed by regulatory agencies.
  * Tracking of final audit result (repayment amount) versus initial audit repayment request)
• Coordinates, supervises, and performs medical record audits of documentation, coding and billing for technical and professional services, including:
  * CPT
  * ICD9
  * HCPCII
  * DRG
  * APC
  * APG
  * Modifiers
  * Teaching Physician Guidelines
  * Non-Physician Practitioner Documentation ( including “incident-to” guidelines)
  * Ensuring MMC employees understand and comply with rules and regulations. Mitigating risk of audits, corporate integrity agreements, fines etc. imposed by regulatory agencies. Avoid repetitive deficiencies in establishing process
  * Monitor level of compliance/adherence to rules and regulations on the federal, state, and local level through regular and ongoing audit activities.
• Conducts audits of electronic and manual documentation, coding, and billing systems.
  * Ensuring MMC employees understand and comply with rules and regulations. Mitigating risk of audits, corporate integrity agreements, fines etc. imposed by regulatory agencies
  * Monitor level of compliance/adherence to rules and regulations on the federal, state, and local level through regular and ongoing audit activities.
• Communicates with external agencies regarding audits.
  Participates in development of voluntary disclosures and repayments to federal and state agencies.
  * Ensure timely and accurate response to external audit, in order to mitigate Medical Center risk (financial and reputational) imposed by regulatory agencies.
  * Tracking of final audit result (repayment amount) versus initial audit repayment request)
• Develops formal audit reports of findings and recommendations, which are presented to senior management of applicable department, the Executive Compliance Committee and the Board of Trustees.
  * Ensuring transparency of findings and communications. Implementation of corrective action and education as appropriate
  * Monitor level of compliance/adherence to rules and regulations on the federal, state, and local level through regular and ongoing audit activities.
• Conducts close-out meetings with senior management of applicable department.
  Coordinates audit activities with Internal Audit, as necessary.
  Identifies compliance risk areas and develops action plans accordingly.
  * Ensuring transparency of findings and communications. Implementation of corrective action and education as appropriate
  * Monitor level of compliance/adherence to rules and regulations on the federal, state, and local level through regular and ongoing audit activities.
• Develops and coordinates analysis of encounter forms and documentation templates
  * Ensuring all encounter forms are accurate and up to date.
  * Ensuring documentation templates are in compliance with established rules and regulations.
  * Review of updated forms
• Audits and enforces compliance policies and procedures.
  * Ensuring all policies and procedures are accurate, up to date, and in compliance with established rules and regulations.
  * Review of updated policies and procedures
• Develops and conducts documentation, coding and billing curriculum and education classes for 500 + physicians, allied health professionals, and coding and billing associates annually, including:
  * One-on-one education sessions based on audit findings
  * Topic-specific group education
  * Mandatory Compliance education
  * Compliance Monthly education calendar sessions
  * Grand Rounds
  * Monthly Faculty Meetings
  * Ensuring that the Medical Center has documented evidence of its commitment to compliance and training. Ensuring that training occurs frequently and ongoing, as mandated by NY OMIG.
  * Tracking of attendees in compliance training database.
• Assists with distribution of all Medicare and DOH updates and code changes to the appropriate associates.
  Facilitates responses to compliance-related inquiries (phone, e-mail, in-person).
  * Ensuring that the Medical Center has documented evidence of its commitment to compliance and training. Ensuring that training occurs frequently and ongoing, as mandated.
  * Increased associate awareness of rules and regulations

Qualifications

• Bachelor Degree Required
• Minimum 5 Years of Billing, Coding, and Documentation experience in a hospital setting Required
• Coding certification (such as CCS, CPC, RHIA, RHIT) Required.
• Needs to be familiar with both facility and professional documentation, coding and billing rules and regulations.
• Needs to be able to navigate registration, billing, and documentation systems with ease.
• Knowledge of local, state, and federals rules and regulations.
• Able to communicate with all level associates, including senior management and external agencies.
• Excellent written and oral communication skills.
• Highly organized and analytical individual needs to be able to function with a high level of independence, motivate and train associates while maintaining good working relationships

Montefiore Health System, Inc. is an equal employment opportunity employer. Montefiore Health System, Inc. will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.