Compliance Specialist

1. Position Title: Compliance Specialist

 

2. SUMMARY OF DUTIES:
1. Maintains a working knowledge of CPT-4 and ICD-9 coding principles, governmental regulations, protocols and third party requirements regarding billing and billing documentation for multiple specialties including, but not limited to, internal medicine, pediatrics, psychiatry, surgery, family medicine, OB/GYN.
2. Coordinates and conducts all inpatient and outpatient chart reviews based on the compliance program to ensure compliance with coding and documentation guidelines and all governmental rules and regulations. Provides follow-up education to the providers based on the findings of the audits.
3. Achieves and maintains a 95% accuracy in compliance auditing while maintaining an acceptable level of productivity. Accuracy will be monitored by periodic reviews by Supervisor or Manager of Compliance and Coding
4. Develops and interprets reports to assist in the review and analysis of the documentation and coding patterns of providers.
5. Develops and maintains a close working relationship with the clinicians and their staff to assure as full an understanding of documentation and coding guidelines as possible is achieved, resulting in the accurate representation of services provided and diagnoses reported. Provides educational sessions as requested.
6. Assures that all services, identified in the patient’s record and other relevant documents, which are to be billed, are adequately documented in accordance with IL-372 and/or any other regulatory mandates.
7. Maintains a working knowledge of the IDX billing system, the registration process and charge entry.
8. Serves as a resource with regard to the rules for utilization of CPT-4 service codes, ICD-9-CM diagnosis codes and modifiers to optimize reimbursement for services rendered.
9. Works with the training department staff to assure that all training programs are current with regard to changes/updates to documentation and coding rules.
10. Other duties as assigned by Supervisor.

 

3. Machines, Tools, Equipment Operated:

Telephone, copier, adding machine, IDX computer system terminal and IBM personal computer, including word processing and spreadsheet software.

4. Education and Training:

Knowledge of medical terminology, anatomy and physiology, pathophysiology, ICD-9-CM and CPT-4 coding classification systems, regulatory agency requirements, computer literacy and health care statistics computation required. College degree in the health care field or RN preferred.

 

5. Experience:

3+ years fee abstraction and/or billing experience with specific experience in coding and compliance review in a multi-specialty setting. Knowledge of computerized billing system required, IDX preferred.

 

6. Initiative, Judgment and Creative Ability:

Proven analytical, investigative and organizational ability. Proven ability to work with minimal supervision at a high level of productivity. Must be able to communicate both verbally and in writing in a highly professional manner. Must be able to prioritize own work and proceed with a minimum of supervision. Confidential patient, financial and employee information must be protected according to institutional policy.

 

7. Mental, Visual and Hearing Demand:

Position requires close attention to detail and ability to handle multiple tasks simultaneously, telephone and face-to-face contact with other staff and external contacts, viewing a computer monitor and reading computer-printed reports, and ability to meet deadlines and work with frequent interruptions. Continuous attention to detail required. Must demonstrate flexibility and be able to function under pressure.

 

8. Reports and Records:

Access to highly confidential information and reports including utilization and reimbursement reports and patient charts.

 

9. Contacts:

Physicians, staff and other hospital and skilled nursing employees.

 

10. Comments:

Ability to work independently and as part of a team is critical. Must have excellent command of the English language. Must be able to make decisions based on sound judgment. Must be punctual and maintain an excellent attendance record. Ability to maintain professional attitude at all times. Incumbent must consistently adhere to department standards for professional office environment. Must be articulate, mature and highly organized.