Compliance Auditor Senior

Company Allegheny Health Network

Job Description

GENERAL OVERVIEW Senior auditor responsible for clinical or physician compliance topics. Assigned the most complex clinical/documentation/coding/billing reviews. Provides guidance to other auditors within AHN on audit approach and analysis. Responsible for creating and overseeing orientation of auditors. Leads all hospital or physician audits/investigations auditing support and responses related to external audit activity. Essential

Responsibilities

Establishes and implements orientation for all members of the AHN audit compliance team. Evaluates the progress of team members including review of reports and audit activities. Works with senior management responsible for AHN-wide case management/physician programs to develop processes that meet Medicare and 3rd party payor requirements. Provides guidance to staff auditors on audit topics and reports. (20%) Conducts educational sessions for hospital/physician staff. (10%) Conducts investigations and performs special projects as assigned. (10%) Compliance Auditor- Sr. (Clinical Specialty) Only Audits/oversees the auditing of 340B program and provides guidance to 340B management team. Participates in meetings specific to case management/UR and assists with 340B regulatory requirements and when needed monitors corrective actions. Analyzes and summarizes PEPPER reports and recommends high risk areas for audit. Conducts audits of Medicare/Medicaid and other third party payor accounts for documentation medical necessity coding (non DRG) charging billing and compliance with state and federal regulations. Prepares accurate and concise written audit reports. Works with auditees on corrective action plans and educate management physicians utilization review/case management staff and/or hospital personnel on documentation billing coding requirements. Responds to external audits of the government (facility based) sent to the compliance office and works with operational owners to establish and implement corrective actions when needed. Advises UR/CM in defending payor claims denials for medical necessity coding billing and documentation through coordination of and/or participation (when appropriate) in the appeal process (RACS ZPICs MICs and OIG audits in particular and other payors as assigned.) (30%) Compliance Auditor- Sr. (Physician Specialty) Only Analyzes E&M bell curve reports and recommends high risk areas for audit. Manages the database of new providers and assigns for audit/education to team members. Participates in meetings specific to physician coding billing and documentation and when needed monitoring of corrective actions. Performs internal concurrent prospective and retrospective audits to assure that billed services are supported by documentation in the medical record and that all coding and documentation is compliant with appropriate guidelines and federal and state regulations. Develops audit detail summary spreadsheets and reports to address any coding documentation or financial discrepancies. Conducts presentations of final audit findings to department staff physicians and appropriate individuals. (30%)

Qualifications

Minimum For Compliance Auditor - Sr. (Clinical Specialty) Bachelor's degree in nursing For Compliance Auditor - Sr. (Clinical Specialty AND Physician Specialty) Bachelor's degree or equivalent education and related experience 7 years in utilization review case management hospital/physician coding and documentation audits/reviews Experience with medical necessity denials/appeals Preferred For Compliance Auditor - Sr. (Clinical Specialty Master’s degree) For Compliance Auditor - Sr. (Physician Specialty) RHIT RHIA certification Knowledge of a variety of clinical specialty areas practices and procedures as well as 340B program

Disclaimer

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties responsibilities and qualifications required of employees to do this job. Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities employees may have access to covered information cardholder data or other confidential customer information that must be protected at all times. In connection with this all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws rules and regulations as well as company policies and training requirements.

Pay Range

Minimum $34.29

Pay Range

Maximum $54.25 Base pay is determined by a variety of factors including a candidate’s qualifications experience and expected contributions as well as internal peer equity market and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal state or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process please contact the email below. For accommodation requests please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees Contractors and Applicants Notice