Coding Compliance Consultant III United States
Researches, plans, executes, presents and reports a broad portfolio of risk adjustment, encounter data, coding, billing and other compliance related audits, initiatives, and investigations to enable organizational compliance with all applicable federal, state, local regulations/laws and business requirements, as well as overseeing the protection of organizational assets. On an on-going basis, researches and interprets risk adjustment, encounter data, coding, billing and other compliance related regulations, laws and business requirements to plan and perform compliance audits, initiatives or investigations. May develop and/or deliver training and communications/change management relative to new standards. Assesses organizational systems (both process and data (outcomes) related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May be responsible for project management relative to new compliance initiatives, products, or annual processes.
- Manages, creates, and maintains client relationships.
- In adherence with the KP Compliance Framework, fosters comprehensive compliance management through a series of activities to comply with all applicable regulations and statutes. Activities include: Planning: identifying compliance accountabilities; identifying internal and external resources; developing Compliance, Work, and Audit plans; participating on and may establish compliance-related committees/work groups; and managing external agency relations. Implementing: identifying compliance requirements and conducting related analyses; creating or revising compliance standards, policies, and procedures; developing and/or conducting compliance and ethics training; monitoring compliance adherence; and reporting on compliance efforts and programs. Validating: reviewing compliance programs and content, including designing and conducting risk assessments and/or audits, and investigating instances of reported non-compliance.
- Researches and stays abreast of regulations and statutes. Determines impacts of implementation of new regulations and statutes and required notifications, changes, and training. Communicates required changes, develops tools to assess risks, and leverages existing workgroups/etc. to facilitate required changes.
- Effectively prepares a well-developed audit approach and documents high quality working papers for complex risk adjustment, encounter data, coding, billing and other compliance audits.
- Responsible for planning, conducting and documenting for complex risk adjustment, encounter data, coding, billing compliance audits/initiatives and other duties as assigned.
- Understands & documents business systems/processes using narrative &/or flowcharting techniques.
- Analyzes audit findings, determines -causal factors-, formulate opinions, cites specific regulations/standards, and develops recommendations
- Prepares working papers documenting & supporting compliance audit procedures and results. Ensures that working papers contain adequate evidence to support audit findings.
- Expected to continue developing broad, in-depth audit knowledge, experience & skills, as well as the ability to function independently & as a team member.
- Works closely with team members, operational leaders and physicians on key risk adjustment, encounter data, coding and billing issues.
-Researches and stays abreast of risk adjustment, encounter data, coding and billing regulations and statutes. Communicates required changes and develops tools to validate pertinent data.
-Demonstrates good interpersonal skills and communicates effectively both verbally and in writing.
- Prepares accurate & timely formal written reports & makes oral presentations to management on findings & recommendations.
- Provides periodic informal work guidance/direction to, and training of team members with less experience.
- Work under the guidance of an Auditor-in- Charge (AIC).
- Minimum five (5) years of health care compliance, health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience.
- Bachelor's or clinical degree, OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
Licenses, Certifications, Registrations
- Thorough knowledge of health care compliance policies, practices and systems.
- Thorough knowledge of health care and related compliance issues.
- Complete understanding of compliance principles, theories, and concepts.
- Full knowledge of health care industry practices and standards.
- Ability to draft and revise documents including policies, standards, analyses, and reports.
- Project management skills.
- Must be able to work in a Labor/Management Partnership environment.
-3-5 years of Professional and Hospital (inpatient and outpatient) coding and billing experiences.
-Proficiency in The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM,) The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) Level II coding
- Instruction in ICD-10 may be considered in lieu of ICD-10 coding experience.
-Very knowledgeable with Hierarchical Condition Categories (HCC) for both Centers for Medicare & Medicaid Services (CMS) and The U.S. Department of Health and Human Services (HHS).
-Comprehensive knowledge of medical diagnostic and procedural terminology.
- Demonstrated experience in conducting Medical Record audits and ability to interpret and apply Federal and State regulations, coding and billing requirements.
-Demonstrated experience in presenting audit findings to Operational leaders.
- Certified Coding Specialist (CCS) and Certified Professional Coder (CPC) certifications - highly preferred.
- Able to work well under pressure and meet strict deadlines.
-Comfortable learning and using web-based audit tools.
- Advanced knowledge of Microsoft Excel, Word, and PowerPoint.
-Ability to travel 10%.
- Registered Health Information Administrator (RHIA) or (Registered Health Information Technician) RHIT.
Primary Location: United States,United States,Pasadena
Scheduled Hours (1-40): 40
Working Days: Mon - Fri
Job Type: Standard
Employee Status: Regular
Employee Group: Salaried, Non-Union, Exempt
Job Level: Individual Contributor
Job: Compliance / Privacy / Regulatory
Public Department Name: National Compliance Ethics & Integrity Office
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
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