Compliance Specialist-PB Audit

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.

General Description of the Job Class

Implement and maintain coding compliance programs in accordance with the Office of Inspector General's work plan to reduce institutional and individual provider legal and financial risk through internal audits, training, and education. Additionally, it improves reliability, accuracy of payment, and quality of care with improved documentation by identifying, training, educating, capturing, and submitting valid medical diagnoses.

Duties and Responsibilities of this Level

                                                           70%

• Thorough understanding of clinic coding ( E/M) documentation requirements and concepts impacting population Heal the Risk Adjustment reimbursement initiatives

• Ability to review documentation and abstract all codes with specific emphasis on identifying the most accurate severity of illness according to CMS guidelines

  • LeverageHealthcare Healthcare Effectiveness Data and Information Set (HEDIS) to measure provider performance on important aspects of care and service

  • Collaborate with CDI Representative to provide timely feedback that will assist with validating and reporting appropriate measures of accuracy

• Offers recommendations and develops templates and tips for capturing the HCCs at the patient encounter

• Serves as an HCC subject matter expert in conjunction with CDIS program(s) to providers, practice managers, PRMO leadership, and Duke Healthcare stakeholders

• Coordinate activities related to coding quality assurance/audit. Be actively engaged in coding, abstracting, and medical data research to include review and analysis of data input, processing, and data output activities.

  • Develop and present educational training programs to hospitals and medical Review of Payers and review of coding queries.

    Conducting staff and maintaining educational collaborations such as Bulletincts, both random and focused reviews on a regularly scheduled timeframe for accurate documentation and coding, which is then reported to coding operations.

  • Identifies coding and billing risk areas and communicates timely through the appropriate channels and forums for those that require escalation.

    Collaborates with internal staff in the development of improved capabilities in coding and compliance. Responds promptly to external and internal concerns about correct coding policies.  Identifies errors on claims and sends them to the claim correction department for processing.

    Assists with the education of providers regarding compliance and government regulations, with special attention to CMS and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and fraud and abuse with periodic updates.

  • Maintains knowledge regarding policies and procedures with Medicare/Medicaid Carriers and third-party payers, including HCC and RAF guidelines

    Collaborates with the Internal Compliance Department to promote excellence in incorrect documentation and coding.

    Interacts effectively and professionally with colleagues to provide helpful information in response to inquiries, concerns, and requests.

    Develops and maintains strong working relationships with both internal and external customers.

                        20%

• Provide documented education (e.g., PPT, handouts, training materials, etc.) to be submitted to the Quality Audit/Review SharePoint). 

• Presents 4–7 education sessions each year with evaluations

• Assists in the financial goals of the department through individual efforts as well as encouraging excellence in others via collaboration.

•  Adheres to all internal policies.

• Actively promotes a better DUHS work environment and a positive atmosphere in which to work.

• Exemplifies DUHS core values and encourages others to follow this high standard. 

• Shows respect and value for others at all times. 

• Participate in multiple employee engagements that align with the Covenant mission

                                  10%

• Performs other duties as assigned by management

• Perform other related duties incidental to the work described herein:

• Maintains all coding credentials for I-10, HCC, and other training and education.

• May participate in payer testing

• May work with HLI staff and DUHS staff to provide data analysis

• < span>May work collaboratively with IMO/MC teams to identify critical language and coding needs.

• Anticipates needs of DUHS regarding 10/I11 data analytics, preference lists, and mappings/crosswalks

Work requires an organization, 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 DRGs and APR-DRGs 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.