Enterprise Compliance Auditor/Educator

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Ensure that WVU Medicine remains in compliance with federal healthcare program rules, regulations, administrative requirements, and guidance. The Enterprise Compliance Auditor/Educator will assist with the development of policies and procedures and their monitoring to assure continued compliance with federal and state regulations. May attend meetings representing the Compliance Department.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, EXPERIENCE AND/OR LICENSURE:

1. High School diploma or equivalent AND Five (5) years of progressive experience in a healthcare organization with extensive knowledge of hospital revenue cycle processes and knowledge of related hospital regulatory and/or payor guidelines  OR 

Bachelor’s Degree AND Two (2) years of progressive experience in a healthcare organization with extensive knowledge of hospital revenue cycle processes and knowledge of related hospital regulatory and/or payor guidelines.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Health Care Compliance Association (HCCA) Certified in Healthcare Compliance (CHC) certificate to demonstrate knowledge of a Compliance Program.

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. Participates in the annual and on-going assessment of regulatory and administrative risk and contributes to the development of the annual compliance work plan.

2. Formulates and defines, along with the Director of Hospital Compliance and VP of Corporate Compliance, the scope and objective of audit or review.

3. Evaluates the scope of the audit and develops and 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. 

4. Independently communicates and interacts with varying levels of staff from each of the system entities, including but not limited to executives, management, and front line staff in order to conduct and bring to closure areas of audit and/or corrective action.  Additionally, the auditor/educator must be able to document these communications and interactions effectively as part of the formal report. 

5. Independently conducts compliance-related audits and reviews to insure regulatory and administrative requirements are met, prepares a formal audit report, and recommends corrective action. 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.

6. Responsible for supporting revenue integrity controls through analysis and auditing of the charge capture process, physician and hospital coding principles, physician and hospital billing regulations, and reimbursement policies applied by federal and/or state regulations and contracted commercial payors.  Based on the findings and results, communicate the summary and work with each stakeholder to develop and implement corrective action including initiation of any necessary refunds and/or self-disclosures that may be required, provide input on revision of work flows in the EMR or other applications, etc. .

7. Performs regulatory, policy and industry research to develop a thorough understanding of the complex federal and state regulations and administrative policies.  Researches WVUHS and facility specific policies and applies the policy and associated process concepts to the audit sample.

8. Reviews medical record billing, and other related documentation.

9. Authors and submits to the Enterprise Director of Hospital Compliance summaries of the completed audit to be included in the update provided to the entity level Board of Directors Compliance and Audit Committee and WVUHS Board of Director’s Compliance and Audit Committee.  The summaries include subject background, findings, statistics, recommendations, and any corrective actions.

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

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

12. Based on regulatory and policy; plans, develops and conducts educational  presentations

13. May serve as compliance representative on assigned teams or committees to provide input and ensure that reporting systems, procedures, and processes are modified 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. Extended periods of sitting. 

2. Extended periods of computer and telephone usage. 

3. Must be able to move throughout the department work areas. 

4. Must have clarity of speaking and hearing.

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. Excellent organizational and time management skills preferred.

2. Excellent written and interpersonal communication skills.

3. Excellent presentation skills preferred.

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

5. Ability to work independently and manage multiple priorities and deadlines.

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:

500 W Berkeley StreetUniontownPennsylvania

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.