Responsible for ensuring that all aspects of documentation, coding, and billing practices are in compliance with applicable laws, regulations, guidelines, and UMMS policies and procedures. Conduct audits to identify areas of non-compliance, assess risks, and collaborate with key stakeholders to monitor corrective measures when indicated. Responsible for validating that data abstracted from the electronic health record (EHR) is coded according to ICD-10-CM, CPT, HCPCS, AMA CPT guidelines, E/M guidelines, and CMS standards. Work is performed under limited supervision. Direct report to the Manager, Coding Compliance Training.

Primary Responsibilities

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.

• Conduct independent compliance audits and review on the adequacy of medical record documentation to support the codes selected by providers and/or coders.
• Verify compliance with CMS guidelines, CPT, HCPCS, and ICD-10 standardized code sets, and internal coding and billing policies via documentation and coding review audits.
• Assist with reporting audit results, trending and tracking regulatory updates, responding to compliance inquiries, preparing education materials, and providing compliance educational support and training to providers and/or coders.
• Perform compliance documentation and coding audits using department's MDaudit software.
• Analyze documentation and/or coding patterns by a provider, division, or department that poses a compliance risk and provide recommendations to mitigate risks.
• Present audit findings and recommendations to key stakeholders including but not limited to individual providers, provider groups, and practice administrators.
• Develop and administer training and educational materials to address documentation and coding deficiencies identified in audits; support the development and administration of system-wide compliance education (e.g., New Provider Compliance Education and Annual Compliance Education).
• Prepare reports for the Chief Compliance, Audit and Provider Officer, Vice President, Compliance Operations, Director, Revenue Cycle Billing and Coding Compliance, Manager, Coding Compliance and Training, UMMS Executive Management and the Audit and Compliance Committee of the Board of Directors.
• Conduct regulatory research, prepare draft responses to compliance inquiries for providers, administrators, and management.
• Monitor, track, and report regulatory updates regarding government billing and coding regulations.
• Log compliance incidents, inquiries, and investigations and supporting documentation in department's case management system; complete assigned cases.
• Support compliance investigations.
• Draft policies, standard operating procedures, and prepare tools (e.g., toolkits, checklists).
• Meet department key performance indicators including but not limited to case turnaround time, audit productivity, and quality metrics.
• Perform other duties as assigned.