Conduct health-system wide compliance audits to ensure data integrity, compliance with federal and state regulations pertaining to but not limited to: federal healthcare program requirements, clinical trials billing, privacy, conflict of interest, and anti-kickback and physician relationships. Exercise independent decisions using analytical and problem-solving skills. Provides critical analytical and support with respect to third party payer external audits (i.e. RAC, ADR/TPE, UPIC, etc.).
Interpretation of applicable federal and state law and regulations to plan audit parameters, determine department's compliance with such regulations and communicate to department necessary changes in compliance with regulatory requirements.
Responsible for conducting routine and non-routine audits, documenting & communicating findings and recommendations, explaining regulatory requirements, and overseeing the corrective actions for audits as assigned (20%).
Develop an understanding of the operations, system processes and procedures used in areas being audited.
Review and test for compliance with institutional policies and procedures, applicable laws and regulations through the inspection of physical operations, processes, retrieval and review of documents and investigation of irregularities and errors (20%).
Compile information and/or prepare reports and analyses setting forth results of compliance audits with appropriate recommendations; perform subsequent audits to ensure complete and appropriate corrective action (20%).
Actively participates in exit conferences, providing clarification and supporting information necessary.
Responsible for overseeing external audits including but not limited to RAC, TPE, QIO, and UPIC, in partnership with PRMO Revenue Integrity team, including preparation and distribution of monthly activity reports (15%).
Responsible for completing voluntary refunds in compliance with Medicare 60 Day Overpayment Rule, including overpayment determination, preparation of refund letter and supporting attachments, and submission of refunds to respective payors (25%).
Performs such other functions as may be assigned from time to time.
EDUCATION Work requires organizational, analytical and communication skills acquired through the completion of a bachelor's degree program. Graduate Degree in finance/accounting or healthcare related field preferred.
EXPERIENCE Strongly prefer 3 years of experience related to auditing and/or coding with progressive experience in auditing, coding compliance, revenue cycle and/or health information management.
LICENSURE/CERTIFICATION None required, but auditing certification (i.e. CPA, CIA), or coding certification (i.e. CPC, CCS, CIC, RHIA, RHIT) or applicable experience is preferred.
KNOWLDEGE, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS
Knowledge of revenue cycle compliance, Medicare/Medicaid regulations, including billing, coding, and documentation requirements.
Knowledge of the various payment systems including DRGs, APCs, and various managed care and capitated arrangements.
Knowledge of RAC, TPE/ADR, QIO, and UPIC external audit processes, including Medicare/Medicaid appeals process.
Knowledge of the auditing process including various techniques relative to auditing and root cause analysis and resolution.
Strong oral and written communication skills, and strong Excel and analytical skills
Required Qualifications at this Level
Work requires a general business background generally equivalent to a Bachelor's degree in a business administration, accounting, management, healthcare administration, other related degree.
Four years of experience related to legal, regulatory compliance, patient advocacy, supervisory role in patient financial services or HIM services, or other relevant experience.
Degrees, Licensure, and/or Certification
Knowledge, Skills, and Abilities
Knowledge of billing compliance, knowledge of Medicare/Medicaid regulations, including billing, coding and documentation requirements. Coding certification (e.g. CPC, CCS, RHIA, RHIT) or applicable experience is preferred.
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
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