Senior Consultant – Healthcare Compliance
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Job Description
Senior Consultant in Healthcare Compliance Practice assisting clients with audits, education, and data analysis. Required coding expertise in inpatient and outpatient settings with remote flexibility.
Responsibilities:
- Perform comprehensive audits of facility and outpatient/professional claims for coding accuracy (i.e. CPT, HCPCS, ICD-10-CM/PCS, DRG, APC, and E/M levels)
- Review clinical documentation and coding to ensure compliance with relevant payer policies, as well as applicable Federal and State regulations and coding guidelines.
- Conduct education sessions for physicians and other qualified healthcare practitioners based on results of clinical documentation reviews
- Review billing practices for facilities and practitioners across the continuum of care.
- Perform independent research, assessment and remain current with CMS, NGS Medicare, and Office of Inspector General (OIG) regulations, guidelines, bulletins, coding practices & methods, annual, semi-annual, and quarterly coding updates and other publications for impact on Institutional services.
- Monitor daily notifications and listservs such as CMS, Medicare, NGS, AHIMA, etc., and third-party payers for updates and changes in regulations and professional and peer organizations/practices/policies/guidelines to keep current with regulatory requirements and accepted compliance and audit practices.
- Analyze paid claims data reports and develop risk informed audit plans.
- Assist with development, review, and maintenance of compliance-related policies, procedures, and workplans.
- Identify, assess, and escalate potential compliance risks, including billing, documentation, privacy, and regulatory concerns.
- Assist clients with regulatory inquiries and payer reviews and participate in special compliance projects (e.g., external audit response, RAC review).
- Analyze large data sets from EMR, billing systems, and audit tools to identify patterns, outliers, and compliance risks.
- Develop dashboards and reports to present audit findings, trends, and actionable insights to leadership and compliance officers.
- Recommend actionable improvements to policies, workflows, and coder/provider performance
- Remain current with changing compliance and audit issues through ongoing education and outreach efforts.
- Safeguard Protected Health Information (PHI) through adherence to HIPAA privacy and security standards in all documentation and communication
- Perform other duties as assigned.
Requirements:
- Minimum 3-years recent experience of MS-DRG, AP-DRG and APR-DRG, professional and outpatient CPT and ICD-10 coding/auditing with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
- Experience in developing and providing audit outcomes to practitioners and staff
- Skilled in applying the official coding guidelines, coding clinic determinations and CMS and other payer and regulatory compliance guidance.
- Requires expert coding knowledge - DRG, APR-DRG, ICD-10, CPT, HCPCS.
- Demonstrable Proficiency in using Word, Outlook, Excel, and PowerPoint
- Excellent written and verbal communication skills.
Benefits:
- Eligible employees have access to benefits that go beyond what’s expected to support their physical, mental, career, social, and financial well-being.
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