Senior Compliance Auditor

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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