Compliance Specialist

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke Health's Patient Revenue Management Organization

Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions.

Occ Summary

Implement and maintain compliance programs in accordance with the Office of Inspector General's work plan to reduce institutional and individual provider legal and financial risk through education and internal audits.

Work Performed

Educate practitioners regarding compliance with government regulations, with special attention to the Centers for Medicare and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and fraud and abuse, with periodic updates.Assist in performing analysis of current situations and recommend priorities and goals for future clinic needs. Identify coding and billing risk areas, conduct focused reviews, and implement corrective action as needed. Conduct routine internal audits of provider documentation on a timely basis. Collaborate with physicians and internal staff in the development of improved capabilities in the areas of documentation, coding, and compliance. Review internal controls, policies, and procedures to ensure compliance with appropriate university, state, and federal guidelines and policies, sound business and finance practices, and overall clinical goals and objectives.Respond promptly to external and internal concerns; implement corrective actions as appropriate.Communicate with Medicare and Medicaid carriers and third-party payers regarding policies and procedures.Promote compliance initiatives with clinical faculty and administration.Perform other related duties incidental to the work described herein.

Monitor data quality and optimal reimbursement to the hospital by performing concurrent and prospective quality reviews for accurate coding and sequencing of ICD-10-CM diagnoses and CPT-4 procedures (and appropriate use of modifiers) for inpatient and outpatient services using C enter for Medicare and Medicaid coding guidelines, standards and regulations.

35% of time spent

•  Interpret guidelines, applicable laws and regulations concerning hospital coding published in AHA Coding Clinic, AMA CPT Assistant, Federal Register, Medicare Bulletin, etc.  Develop and maintain specific coding guidelines for inpatient and outpatient coding.  Research problem areas and develop training material and coding aids for the coders.
• Present timely, relevant educational programs to coding staff regarding coding updates, documentation and prospective payment system requirements.  Participate in the training of the coders and evaluate the effectiveness of the training.
• Maintain or update the coding compliance manual.
• Monthly report on findings to codination staff and others (including the Compliance Department).

B. Identify coding and billing risk areas for hospital technical charges, conduct focused reviews, report the results, and implement corrective action as needed.30% of time spent

•  Serves as the technical expert for questions
•  Conduct routine internal audits of coded data and physician doc umentation, report the results and recommend corrective action as needed
• Serve as a resource to the hospital on coding and documentation-related issues.  Educate physicians andother health care professionals r egarding documentation requirements for accurate coding and reimbursement. Educate administration, financial management, patient resource management, revenue managers, etc. regarding APCs and the reimbursement methodologies.

30% of time spent

• Collaborates with HB Coding, Billing, and others for process or system changes.
• Participates in the creationand execution of educational initi atives associated with HIM strategies
•  Effectively communicates verbally and in written form, including the provision of updates to Manager and Supervisor regarding the operation of work unit, project status, and staff issues

D.  Other: 5% of time spent

• Performs other related duties incidental to the work described herein and perform s other related work as required

• Four (4) years of coding review experience in applying compliance, auditing and coding principles as they relate to reimbursement and other related revenue cycle functions.

• Experience in the formal teaching of coding is preferred.

• Or an equivalent combination of relevant education and/or experience.

• Registered Health Information Technician (RHIT) and/or Certified Coding Specialist (CCS) are required

Knowledge of:

• ICD-10-CM and PCS, HCPCS, and CPT coding guidelines to effectively apply to inpatient or outpatient diagnoses and procedures.
• Knowledge of prospective payment systems and a thorough understanding of DRG/APC reimbursement methodologies and coding validation.
• Understanding of anatomy, physiology, pharmacology and medical terminology.

Ability to:

•  Achieve thoroughness and accuracy in tas k completion
• Analyze detailed information to determ ine appropriate compliance with coding and reimbursement regulations
• Establish and maintain effective working relationships
• Communicate clearly and concisely
•  Epic experience preferred: 3M 360 CAC, Encoder
• MS Office Applications (Word, Excel, Visio, Access, Power point)

Work requires an organizational, analytical and communication skills program. generally acquired through the completion of a Bachelor's degree

Four years of administrative experience to acquire competence in applying compliance, coding and auditing principles as they relate to insurance billing, collections, consulting, and other revenue cycle-related functions. For technical coding, two of the four years of experience with DRG's and APR-DRG's are required. Experience in the formal teaching of coding is preferred. RHIA, RHIT or CCS are required. For professional coding, specialty coding experience in surgical or E/M coding is preferred. CPC, CCS, RHIT, RHIA or CPMA are required.

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.