Compliance Reimbursement Consultant

Overview

Primary Purpose
Supports the Compliance and Integrity Department with risk-based reviews of hospital and/or physician documentation, coding, and billing issues. Performs reviews, research, data analysis and investigations, tracks and analyzes compliance activities and prepares compliance and regulatory educational materials.

Major Responsibilities
* Contributes to the development (through risk assessment), execution, and updating of the Compliance & Integrity Department's annual compliance work plan, with focus on reviews impacting health system reimbursement
* Conducts and/or leads Enterprise compliance reviews and investigations impacting hospital and physician reimbursement., Participates in other compliance activities including design and documentation of the review/investigatory methodology.
* Performs data collection for proactive reviews and investigations of potential compliance issues. Assists in other compliance activities such as risk assessments, surveys, etc. Participates in the use of analytical software and statistical sampling techniques to identify compliance concerns.
* Collaborates with various departments to obtain information needed in conducting risk-based reimbursement reviews, and investigations. Uses the collected information to scope the reviews and investigations, develop statistical sampling methodologies, and conduct the reviews.
* Prepares reports of reviews and investigations and delivers the results to Operational Leaders.
* Facilitates and/or assists in the design of corrective action in departments throughout the Enterprise to promote compliant practices and processes.
* Performs tracking and follow-up to ensure all identified corrective actions are complete.
* Preparing documentation and communication to report compliance repayments to governmental agencies and other payors.
* Assists in creating education and communication material for internal and external audiences on compliance issues.
* Partners with leadership to establish ongoing compliance monitoring and reporting. Performs follow-up activities to ensure corrective action plans have been implemented and maintained.
* Prepares routine reports for Operational leaders and Compliance Committees regarding the compliance review activities and actions taken and creates reports for regulatory agencies as directed.
* Reviews and opines on clinical services involving new services and/or external vendors.
* Performs research related to regulatory requirements involving health system reimbursement. Prepares regulatory guidance documents to share with other members of the Compliance & Integrity Department and Operational Leaders.
* Completes special compliance related projects as needed.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so you can live fully at and away from work, including:

Compensation

Base Pay: $72,592.00- $108,888.00 annually

Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Benefits and more

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

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Minimum Job Requirements (avoid arbitrary education and experience that cannot be validated)
Education (minimum education level and field of study)
Bachelors Degree or equivalent knowledge in Health Care Administration, Medical Coding, Health Information Management or health related field.
Certification / Registration / License (any certification, registration, license required to perform the job followed by the governing body)
CCS, CCS-P CPC, CHC or CRCR certification required
Work Experience (the minimum years and type of experience required for competent performance of the job)
Typically requires 5+ years of experience in a health care environment with knowledge of health care regulatory requirements and medical coding and billing experience.
Knowledge / Skills / Abilities (Knowledge is considered a body of information necessary to perform a task, skills are a level of proficiency needed, and abilities are capabilities necessary to perform the job)
* Working knowledge of compliance related regulations such as coding, billing, documentation requirements, Local and National Coverage Determinations, National Comprehensive Coding Initiatives, Medicare/Medicaid billing regulations, HIPAA Privacy rule, etc.

* Strong computer, problem-solving and analytical skills, including ability to perform data mining to identify aberrant patterns that may be indicative of compliance issues or trends.

* Highly motivated, team oriented, professional, and trustworthy, with strong skills in personal diplomacy.

* Presentation and writing skills to prepare and organize media for delivery of reports and education to physicians, leadership, and teammates.

* Demonstrated ability to handle sensitive communications with leadership, physicians, management, and legal counsel.

* Strong organizational and time management skills.

* Proficiency in Microsoft Office Suite software. Demonstrated ability to prepare spreadsheets and presentation materials.

Physical Requirements and Working Conditions
This position may require travel, therefore, will be exposed to weather and road conditions.

Operates all equipment necessary to perform the job.

Exposed to a normal office environment.

DISCLAIMER
All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position. Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders.