Quality Improvement - Compliance Audit Specialist

Position Summary




Under the direction of the Director of Quality, this position will be responsible for conducting medical record reviews and other audits to monitor for compliance with internal policies and external regulations. This position will also assist in implementation of the Quality and Compliance Management Program including assisting with the development of policies and procedures and the development and implementation of compliance training.




Essential Functions






Performs medical records reviews for services provided by the agency to ensure compliance with regulatory requirements, including, but not limited to, documentation requirements and appropriateness of care.

a. Assist with audit design.
b. Independently completes medical record reviews and audits within
established timeframes, analyzes results, and prepares formal reports
with findings and recommendations.
c. Consults with agency staff for clarification of clinical data. Facilitates and improves organization staff’s understanding of payor and regulatory requirements by providing feedback related to documentation.

Processes additional documentation request received from Medicare, Medicaid and third-party payors to ensure compliance and the maximization of appropriate organization reimbursement.

Conducts medical record reviews related to additional documentation requests.
Identifies potential denials and works with organization staff to strengthen documentation where appropriate.
Coordinates the additional documentation request process including maintenance of tracking logs and preparation of cover letters as required.
Provides updates/reports to the Director of Quality and Risk Manager regarding the status of additional documentation requests.




Participates in review of claims denied by Medicare, Medicaid and third-party payors to ensure both compliance and the maximization of appropriate organization reimbursement.

Assists with the medical record reviews related to denials and documents findings.
Prepares appeals for denial when appropriate based on the review of medical records or coverage criteria, including preparation of appeal templates, forms, and cover letters, as required.
Coordinates the appeals process including maintenance of tracking mechanisms throughout the review process to a final determination.
Prepares reports for the Risk Manager and Director of Quality regarding the status of open denials and appeals.
Participates in the development and implementation of identified improvements to systems/procedures related to reasons for claim denials.




Investigates, responds to, and communicates information regarding documentation, compliance, and reimbursement questions.

Compiles and analyzes data.
Supports, provides analysis for, and advises management regarding documentation issues.
Analyzes documentation issues/questions from a compliance perspective.
Develops and implements a system for documenting and communicating responses to all compliance questions.




Identifies and communicates educational needs based on clinical record audits and other regulatory audits to the Director of Quality and/or appropriate compliance team member.



Assists in developing and providing compliance education to organization staff, including clinical documentation and regulatory changes.

Provides accurate and up-to-date information on regulatory requirements.
Provides expertise for compliance issues.
Assists in the development of compliance education materials.
Prepare reports and graphics for presentations.
Maintains attendance lists for all presentations and logs of issues raised and identified for future research and response.




Maintains current knowledge of industry regulations, issues and best practices and ensures appropriate dissemination and communication of changes to the appropriate members of the Compliance Department.



Participates as an active member of agency committees as assigned, including attending meetings and reporting on projects and findings as requested.



Participates in Team Rounding to patient care teams to solicit feedback and/or provide regulatory updates and education.



Assists management with special projects and performs other duties as may be

required to support the organization’s compliance program.





Qualifications









Knowledge and Critical Skills





Knowledge of:

Demonstrated proficiency with applicable laws and regulations including Medicare, Medicaid, and other third-party payors.
Proficiency in reading medical records.
Excellent verbal and written communication skills.
Knowledge of general research methods, including, but not limited to, research of health care regulatory requirements.
Ability to evaluate medical necessity using governmental regulatory and private payor guidelines and nursing judgment.
Demonstrated experience in providing reports and presentations.


Skilled at:

Ability to solve practical problems and exercise independent judgment in planning work details and making technical decisions related to audits.
Must be detail oriented with strong organizational and multi-tasking skills to meet scheduled deadlines.
Ability to interact on a professional level with agency staff, including clinical and non-clinical staff.
Strong working knowledge of common business-related computer hardware and software, including Word, PowerPoint, Adobe, Excel, and Internet.
Previous hospice work experience preferred.





Experience





3 to 5 years on-the-job experience in healthcare auditing, medical chart review, healthcare consulting, insurance company/intermediary, or may consider clinical experience





License / Certification





Current licensure as a registered nurse in the state of Florida.





Education







Other Requirements





Must have medical clearance for communicable diseases before direct patient contact
Current immunizations including but not limited to TB, Hepatitis, and Flu





The knowledge, skills and abilities listed above are typically acquired through the levels of education and experience listed. However, any equivalent combination of education and/or experience, which provide an applicant with the listed knowledge, skills, and abilities to perform the essential duties and responsibilities of the job, is acceptable.




This description is intended to describe the general nature and level of work performed by employees assigned to this role. It is not intended to be an exhaustive list of all duties, responsibilities, qualifications, or working conditions required of employees in this position. The organization reserves the right to modify or amend the duties of the position or to require that additional tasks be performed as organizational needs change. This description does not constitute a contract of employment, and employment with the organization is at-will, meaning either the employee or the organization may terminate the relationship at any time, with or without cause or notice.