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Healthcare Compliance Auditor - Enterprise Risk

Healthcare Compliance Auditor - Enterprise Risk

Bon Secours Mercy HealthOmaha, NE, US
1 day ago
Job type
  • Full-time
Job description

Compliance Auditor

Works collaboratively with the Compliance Manager on creating auditing protocols which align with Bon Secours Mercy Health's overall compliance audit and compliance responsibilities relative to hospital revenue cycle services performed for Bon Secours Mercy Health.

  • Please note this role is remote, but requires living in the continental US and working hours in alignment with Eastern Time.

Essential Job Functions :

  • Assists in the review of Bon Secours Mercy Health 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 compliance monitors and audit protocols specific to hospital revenue cycle risk areas highlighted by the OIG, Medicare, State Medicaid, State Insurance Fraud; Managed Care or Governmental Value-Based payment programs and / or other enforcement agencies on behalf of Bon Secours Mercy Health.
  • Coordinates periodic review and analysis of Bon Secours Mercy Health hospital 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 revenue cycle risk areas
  • Assists in auditing and investigations requested by the System Director, Compliance.
  • 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 System Director, Compliance is apprised of local, remote and client-network emerging issues, adverse outcomes and / or deficiencies that could impact Bon Secours Mercy Health's public status.
  • Develops educational content on documentation, 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 challenges among affected parties and entities.

    • Qualifications :

  • CCS, CPC, RHIT, or RHIA 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 coding / billing either from a consulting perspective or as an employee / manager required.
  • 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 required.
  • Excellent analytic and problem-solving skills to process auditing and monitoring reports, identify compliance risks and prioritize recommendations preferred.
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    Compliance Auditor • Omaha, NE, US

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