The Clinical Compliance Auditor is responsible for auditing medical records at LMC to assure compliance with all regulatory agencies as well as payers. Possesses full understanding of Medicare guidelines (Local Coverage Determinations) and Medicaid documentation guidelines. Utilizes available medical necessity tools to review documentation for appropriate level of care determination as wells as provide education to staff and physicians on opportunities for improved documentation.
Supports the Chief Compliance and Privacy Officer in providing system wide guidance and support to promote compliance with laws, rule and regulations.
Conducts audit of medical records at LMC and other inpatient clinical areas and measures against applicable criteria.
Collaborates with the Chief Compliance and Privacy Officer and the Sr. Compliance and Privacy Analyst on implementation of the compliance plan.
Assists with developing, coordinating and conducting educational programs on documentation and billing compliance for employees, medical students, and physicians at LMC ensuring that trainings are conducted in accordance with the District’s compliance plan.
Provides on-site support for documentation deficiencies and focuses on areas of improvement.
Reviews medical records prior to submission to RAC,MIC Auditors or others.
Provides ongoing communication with users, managers, and District to assure support and continual understanding of current medical record documentation initiatives.
Ensures proper control systems are in place for areas of risk areas.
Assists with development of annual Compliance audit work plan for compliance.
Ensures annual audit work plan is met with planned audit and monitoring as well as assist in investigation into Compliance related issues to billing and documentation.
Performs audits in accordance with accepted standards and reports all pertinent findings based on the outcome of the audit.
Ensuring requests, inquires, and/or investigations by regulatory agencies are properly managed and coordinated internally. Timely response is paramount.
Monitoring changes in State and federal laws or rules for Compliance related to documentation and billing in order to ensure the organizations maintain superior compliance and communication to appropriate District entities of changes.
Reports audits, risks and violations to the Chief Compliance and Privacy Officer in a timely manner. Develops corrective action plans with appropriate department heads and monitors progress to such plans and updates.
Participates in billing workgroup.
Researches, investigates, and analyzes compliance issues related to billing and documentation and renders professional advice to business areas.
Reviews areas previously audited to confirm proper corrective action or recommendation(s) have been implemented.
Develops quarterly reports of activities and results. Reports information to the Compliance and Privacy Manager.
Assists the Chief Compliance and Privacy Officer in preparing an annual report summarizing compliance activities for the current year and assists in preparing an annual work plan for the next fiscal year based on OIG work plan, regulatory risk and changes in regulatory/billing environment.
Exercises discretion to ensure that information is provided as appropriate and maintains confidentiality.
Demonstrates the ability to dissect difficult problems, analyze the essential components and affect change.
Demonstrates the ability to lead and/or work effectively within teams comprised of subordinates, peers, supervisors and external parties. Requires the ability to investigate issues, gather feedback, build consensus and, when necessary, respectfully disagree.
Exhibits exemplary oral and written communication skills. This includes the ability to share information in an organized, clear and timely manner, both verbally and in writing; keeping peers, colleagues, staff, and Compliance and Privacy Manager and Chief Compliance and Privacy Officer appropriately informed.
Displays effective interpersonal skills such as effective listening, appropriate use of style and language for audience, and productive processing of information.
Processes and synthesizes complex information in an analytical fashion and is able to communicate finding and results effectively. This includes effective verbal presentation and written analysis adjusting language and terminology to the needs of the audience.
Emergency duty may be required of the incumbent that includes working in Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
Bachelor’s degree in Nursing (or RN licensure), Health Information Management, Healthcare Administration, or related discipline required.
Minimum of three (3) years of experience in health care (hospital setting) with knowledge of hospital rules and regulations required. Knowledge of medical necessity requirements for documentation, familiar with the Local Coverage Determination rules for Medicare, familiar with the RAC/MIC audit process and requirements for documentation and billing required. Proficiency with third party billing and documentation standards is required and must be proficient in reading inpatient and outpatient medical records and hospital billing. Direct hands-on clinical experience preferred.
Certified coder preferred.
Valid Florida Driver’s License required.
Current, valid State of Florida nursing licensure preferred.
Demonstrates current knowledge of healthcare through ongoing professional development.