Enterprise Provider Compliance Auditor-Educator

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The Enterprise Compliance Auditor/Educator will assist with the implementation and facilitation of ongoing compliance auditing, monitoring, and educations associated with all provider services across WVUHS and its affiliates. The duties of this position will help ensure that all healthcare provider (MD/DO, APP, and other non-physician practitioners) organizations remains in compliance with all federal healthcare program rules, regulations, administrative requirements and guidance.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, EXPERIENCE, AND/OR LICENSURE:

1. High School Diploma or Equivalent AND Seven (7) Years of experience in multi-specialty coding, E&M coding, procedural/surgical coding OR;

Associate’s Degree AND Five (5) years experience in multi-specialty coding, E&M coding, procedural/surgical coding.

2. Current certification in one of the following:

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Conducts compliance-related audits and reviews. Coordinates with departments to conduct compliance audits and reviews. Such reviews take into consideration the rules and regulations for CMS, multistate (WV, OH, PA, MD, etc.),  and payor specific regulations for chart documentation, valid coding and billing, and medical necessity support to prevent fraud, waste, and abuse as mandated by OIG compliance program requirements. Coordinates with departments to conduct audits across WVUHS and all its affiliates.

2. Coordinates with departments to conduct compliance audits.  Evaluates the scope of the audit and develops/completes the required compilation of data analytical reports (independently of IT and/or Data Analytics) from the appropriate application or software in order to identify the audit universe and then select the appropriate sample based on the scope of the audit criteria. 

3. Formulates and defines, along with the Director of Provider Compliance and VP of Corporate Compliance, the scope and objectives of audit or review.

4. Researches regulatory requirements that pertain to the audit or review.

5. Reviews medical record, billing, or other relevant documentation.

6. Develops and writes audit reports which outline audit findings, recommendations and corrective actions as needed.

7. Leads and conducts meetings with respective departments or individuals to review audit reports and develop corrective action plans as necessary.

8. Planning, developing and conducting presentations for internal and external departments.

9. Coordinates educational activities with the Director of Provider Compliance and VP of Corporate compliance to ensure organizational compliance education needs are met.

10. Conducts and/or facilitates audit training/education activities of the Compliance Department which may include individual or group training based on the results of internal audit reviews.

11. Reviews clinical issues with physician to ensure appropriate physician documentation, coding, and reimbursement.

12. Conducts and/or facilitates educational activities of the Compliance Department which may include individual, group, and/or online training development.

13. Assists in planning of informational programs, education, and training sessions to educate staff, both departmentally and institution wide, of current and changing compliance and regulatory requirements. 

14. Develops and conducts ongoing compliance, documentation guidelines and billing education for new staff, including physicians, allied health and advanced practice professionals, and coding personnel.  Additionally the auditor/educator assists with auditing and education, and acts a subject matter expert to the Enterprise Information Management team for both professional and hospital coding.

15. Development of Policies/Procedures.

16. Assists in review of new or revised regulations or policies issued by regulatory agencies to determine how they apply at UHA and as necessary, other provider groups.

17. Conducts ongoing auditing, monitoring, and/or investigations related to compliance with policies and regulatory requirements.

18. Assists in compilation of compliance statistics, findings, and status updates for reporting. Prepares and submits required information to the Enterprise Director of Provider Compliance summaries of the completed audits to be included in updates provided to specific/designated entities for provider board of director and compliance/audit committees, whether physician practice or hospital based. The summaries include subject background, findings, recommendations, and any corrective actions.

19. Serves as compliance representative on assigned teams or committees to provide input and ensure that reporting systems, procedures, and processes are altered or maintained to ensure compliance with applicable laws, regulations, and policies.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Extend periods of sitting.  Extended periods of computer and telephone usage. 

2. May require large amounts of walking.

3. May require ability to lift and/or carry heavy materials (i.e., written records, reference manuals, files, etc.)

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required.

2. Analytical and problem solving skills.

3. Effective verbal and written communication skills, as well as interpersonal skills necessary to communicate effectively with all levels of management.

4. Capability of working on assignments of varying difficulty and complexity, while exercising independent judgment.

5. Proficient with personal computers and financial application software. 

6. Excellent organizational and time management skills.

7. Excellent presentation skills.

8. Ability to utilize electronic medical record and billing systems.

9. Ability to analyze complex EMR workflows related to documentation, billing and etc.

10. Knowledge of governmental billing and coding regulations including the “Teaching Physician Guidelines”.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Day (United States of America)

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

508 SYSTEM Compliance

Address:

3040 University AveMorgantownWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.