Reporting to the Corporate Director Compliance, manages prospective and/or retrospective inpatient and outpatient professional documentation, coding and billing audits conducted by physician compliance audit staff. Provides supervision of staff including review of work product, reports, corrective action plans and education. Performs audits as assigned by Director. Oversees other areas of physician compliance, including contracts, leases, and sanction checks.
- Manages, supervises and reviews auditing and educational work of the physician compliance auditors. Manages audits of physician contracts and leases and associated corrective actions when needed. Manages staff relations including performance management, staff satisfaction and conflict management. Maintains expertise of staff through educational opportunities.
- Performs internal concurrent, prospective, and retrospective audits and creates written reports to assure that billed services are supported by documentation in the medical record and that all coding and documentation is compliant with federal and state regulations.
- Reviews and analyzes statistical information on employed physician practices. Researches billing and reimbursement compliance issues to provide recommendations for accurate documentation guidelines to ensure compliance with regulatory mandates.
- Oversees complex billing and reimbursement compliance investigations. Identifies audit target areas to proactively correct issues and prevent audits, in addition to recouping lost reimbursements.
- Performs compliance investigations originating from internal or external sources, compiling supporting documentation for results and proposed action plans to address potential areas of improvement and/or noncompliance.
- Bachelors' Degree required or equivalent education and experience.
- National certification as a certified professional coder (CPC) or CCS-P or successful passing of State Bar Exam. Current Driver's License (as car and travel throughout Western PA) is required.
- Minimum 3 years management experience with auditing and physician coding and documentation reviews required OR law degree and 1 year compliance related experience required.
- Demonstrated knowledge of Medicare, Medicaid, and local third party regulations, advanced ICD-10 and CPT coding, physician billing, and medical record auditing expertise or experience with contract and lease review and associated regulations.
- Advanced computer skills in applications such as Microsoft Word, Excel and Power Point along with proficient writing skills, preparation of work papers and reports, and ability to present clear and concise findings (oral and written) are also required.
- Prefer experience in physician office operations.
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