Under the direct supervision of the Director, Compliance Audit, this position contributes to the Mercy Health and Ensemble mission and vision by serving as an auditor of physician services related to Ensemble revenue cycle-third party billing. Ensemble RMC LLC is a owned subsidiary of Mercy Health and provides a wide-range of revenue cycle services to Mercy Health and non-Mercy Health clients. This position provides compliance program-related compliance audit activities relative to Mercy Health and Ensemble operations conducted at local (Ohio) and remote locations (North Carolina) and supports compliance auditing requested by non-Mercy clients as part of contractual obligations.
- Works collaboratively with the Director, Compliance Audit on creating compliance auditing protocols which align with Mercy Health’s overall Corporate Responsibility Program and specific compliance responsibilities relative to Ensemble’s physician revenue cycle-third party billing services performed for Mercy Health as well as non-Mercy clients.
- Assists in the review of Mercy Health and non-Mercy client coding, billing and claims processing policies and procedures for the development of compliance internal monitors and audit protocols and the prevention of fraud, waste and abuse.
- Develops internal compliance monitors and audit protocols specific to physician revenue cycle risk areas highlighted by the OIG Program Guidelines for Third Party Billing Companies, State Insurance Fraud; Managed Care or Governmental Value-Based payment programs and/or other enforcement agencies on behalf of Mercy Health and non-Mercy clients.
- Coordinates periodic review and analysis of Mercy Health and non-Mercy client’ claims denial reports, operational assessment reports, internal quality control reviews, internal and external third party claims payment peer analysis systems to detect provider-billing trends, potential fraudulent or abusive billing practices or vulnerabilities indicative of potential underlying operational compliance issues.
- Utilizes data analytics techniques, statistical analysis and modeling, and databases developed internally, or in conjunction with other third party vendors to detect and trend potential claims and billing compliance issues relative to physician revenue cycle risk areas
- Assists in auditing and investigations requested by the Director, Compliance Audit. Assists in the development of compliance corrective action plans (CAP), oversight tools and technical edit enhancements to support revenue cycle services compliance and privacy efforts. Assists in and tracking of all activities related to recovery and repayment of inappropriate payments discovered as a result of claims audit or investigation.
- Maintains awareness of fraud, waste and abuse laws and regulations and current industry changes that may impact healthcare revenue cycle services domestic and international through personal initiative, continuing education and peer-to-peer networking
- Ensures that the Director, Compliance Audit is apprised of local, remote and client-network emerging fraud, waste or abuse issues, adverse outcomes and/or deficiencies that could impact Ensemble or Mercy Health’s public status
- Develops educational content on documentation and coding and trending of non-compliant activities to enhance compliance proficiency and competency, understanding of standards and the consequences of non-compliance. Prepares multi-faceted oral, written and electronic communications and presentations to facilitate discussion, networking, decision-making and proactive responses to meet current and emerging compliance challenges among affected parties and entities.
Qualifications - Minimum
- Required Minimum Education: Vocational/Technical Degree in Healthcare Auditing, Healthcare or HIM
- Preferred Education: 4 Year Bachelor's Degree
- CPC Required
- Auditing Experience, Experience with EPIC Electronic Medical Records System Preferred
- Two to four years of in-depth experience within healthcare operations, healthcare auditing, or physician coding/billing either from a consulting perspective or as an employee/manager.
- Demonstrated working knowledge of Medicare and Medicaid, Insurance Managed Care including documentation, coding, reimbursement methodologies, as well as extensive familiarity with Department of Health and Human Services Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) rules, regulations and compliance guidance.
- Excellent analytic and problem-solving skills to process auditing and monitoring reports, identify compliance risks and prioritize recommendations.
Equal Employment Opportunity
It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.