Compliance Clinical Senior Auditor

The MENTOR Network is now Sevita. We have a different name, but the same mission, and a renewed sense of purpose. At Sevita we provide home and community-based health care services and support for adults, children, and their families across the United States.

Join us in work that matters.

Summary

The Senior Clinical Compliance Auditor is responsible for developing, auditing plans, and collaborating with Operations and Revenue Cycle in auditing / monitoring compliance requirements across all Company business units and service lines.

Ensures that existing clinical audit standards and procedures are best practice according to legal and regulatory requirements;

payer requirements and expectations; and external and internal standards. Executes clinical audits with the aim of identifying gaps and recommend changes to clinical practices to ensure that optimum care is delivered to the individuals we serve and support.

Collaborates with Ethics and Compliance Officers to contribute to projects related to the Compliance Audit, Self-Monitoring, Data Mining and Risk Assessment programs.

Supports the leadership of the Company and the Chief Compliance Officer.

This position is remote and can be performed from anywhere in the There is some travel required.

• Acts as an accessible, visible and available subject matter expert to the business as it relates to audits.
• Establishes a compliance culture as a strategic, competitive advantage with each audit performed.
• Evaluates the areas of risk to be addressed by each audit. Interprets the relative significance of issues needing resolution;

escalates at appropriate time.

• Assists in the development of the annual Compliance Audit Plan and Company Compliance Plan. Facilitates the development, implementation, and review of compliance and auditing framework to ensure the facilitation of best clinical practices.
• Plans, leads and executes scheduled and non-scheduled compliance audits according to the audit plan while testing compliance with all pertinent billing and coding requirements;

internal policies and procedures; and external accreditation standards; manages audits to minimize resources in audited departments.

Reviews quality, medical, and clinical processes for adherence with company, industry, accreditation, state, and federal guidelines.

Recommends process, procedure, and or policy improvements to mitigate against identified risks.

• Coordinates with clinical operations, revenue cycle departments to ensure accounts audited reflect proper documentation, charge capture, coding, billing and payment.
• Contributes to the identification and reduction of the Company’s coding compliance risks, billing inaccuracies, and / or denials by coordinating independent reviews and assessments of the organization's professional coding and billing transactions, processes, and internal controls for coding completeness and accuracy.
• Designs and performs risk assessments to identify compliance and non-compliance concerns.
• Coordinates and executes pre- and post-payment audits of medical records and associated clinical documentation to ensure proper charge capture and billing in accordance with standard state, federal, and internal reimbursement policies, principles, and mandates.

Assists in the development of recommendations aimed at changes to clinical practices and procedures. Develops and performs mock audits to support continual audit readiness.

• Actively supports the assigned Operating Group's Management team during audits to discuss identified issues affecting the business and operations and to act as a resource for the Operating Group's management team on audit observations.
• Reviews compliance with existing policies and procedures by performing the required audit steps and reviewing internal controls.

Assists with the day-to-day compliance and auditing including chart reviews, investigating actual or potential non-compliance, managing, and analyzing compliance data and serves as a resource to the Compliance Department.

• Prepares audit reports based on audit findings derived from and supported by the audit work papers.
• Provides recommendations requiring management responses to address identified observations or findings.
• Conducts audit exit meetings to review audit report findings.
• Discusses possible management responses with the Operating Group management team to ensure management understands the implications of the observations or findings so that they can respond appropriately.
• Reviews management responses to determine if recommendations have been satisfactorily addressed. Addresses responses requiring further clarification.
• Provide assistance to team members with general tasks that require a better understanding of functions, as directed by immediate supervisor.
• Applies knowledge of compliance and a developed understanding of service lines to all audits and audit projects while working with the Ethics and Compliance Officer and / or business to mitigate the risks that impede the Operating Group's goals.
• Adapts to and reacts to the needs of a rapidly growing and changing business and understand the complexities of a large organization.
• Maintains current knowledge of laws, regulations, and market changes that impact all aspects of the Company, including, but not limited to, Stark Law, Anti-Kickback Statute, Patient Inducement Statute, Health Insurance Portability and Accountability Act, relevant Office of Inspector General (OIG) Model Guidance and applicable Advisory Opinions.
• Works in conjunction with the law department to better understand operational requirements under the law.
• Partners with Ethics and Compliance Officer(s) and respective Operating Group management team(s) in the development and review of new business activities and programs as the audit expert.
• Assists with activities related to outside investigations, including but not limited to potential fraud and abuse issues, which could be either general or targeted.

Assists external counsel in identifying and reviewing pertinent documents.

Participates in activities related to exclusion screening, which applies to new hires, current employees, vendors and providers.

Investigates and resolves any potential matches.

• Ensures necessary follow-up takes place to resolve open items and that controls are in place to successfully mitigate business and regulatory compliance risks.
• Completes special projects and reports as needed by the Compliance Department.
• Performs other related duties and activities as required.

Qualifications :

• Bachelor’s degree in Nursing or other clinical degree preferred
• 2 5 years' experience in healthcare and / or compliance or an advanced degree without experience.
• Professional certification (CIA / CHC) preferred.
• Previous experience in regulatory / compliance audit preferred. Clinical or administrative experience in community-based long term care service programs preferred.
• Knowledge of statistical auditing methods and Medicaid reimbursement preferred.
• Superior ability to communicate orally and in writing to individuals and groups from varied disciplines and levels of management.
• Strong communication, interpersonal and presentation skills, working with both internal and external individuals and entities.
• Ability to motivate, lead and coordinate cross-functional teams of senior management personnel.
• Excellent analytical, problem solving, project management, leadership and team building.
• Strong computer skills with proficiency in Microsoft Office.
• Travel as needed, approx. >

25%.

Why Join Us?

• Paid Time Off, Holiday Pay, and Health Benefits
• Career development and advancement opportunities
• Work with some of the best co-workers you could ask for and see your impact on the lives of those individuals we serve
• Since our funding comes from Federal and State payers, we offer stability and secure work opportunities
30+ days ago