Job Opportunity Job ID: 21401 Positions Location: Lansing, MI Job Description General Purpose of Job: Description:
Positions Location: Lansing, MI
General Purpose of Job:
Responsible for management of assigned internal and external compliance audits consistent with Medicare Advantage Prescription Drug Plan criteria, recommendation and oversight of corrective action plans, and compliance education. The Medicare Compliance Auditor will interact with internal and external compliance stakeholders and must be critical-thinking, thorough, and solutions-focused.
This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
- Perform internal audits and reviews of processes in a thorough and structured manner. Internal audits include audits of first tier downstream related entities (FDRs).
- Participate as a lead representative in all external audits, including audits with the Centers for Medicare & Medicaid Services (CMS).
- Review of billing/reimbursement activities and application of CPT, ICD, Medicare NCDs/LCDs rules.
- Create collaborative, effective workgroups of internal and external stake holders.
- Create audit reports, policies and procedures, or other department communications.
- Data analysis, including ability to manipulate data in Microsoft Excel or other application. Review and assess data and reports for appropriateness for audit and/or potential recovery.
- Participation in and contribution to the risk assessment and work plan creation process.
- Verbal communication and ability to present compliance reports and education to various audiences.
- Strong customer service acumen in responding to and dealing with both internal and external stakeholders.
- Facilitate, plan, and coordinate compliance meetings with internal and external stakeholders.
- Respond to compliance referrals / tips from all sources (e.g., CMS, members, providers, billing personnel, internal staff) concerning compliance issues.
- Analyze national and state trends and incorporate those trends in developing audit structure.
- Develop audit process, including but not limited to, scope of audit, sample selection and depth, methodology utilized and critical analysis of results.
- Participate with Special Investigations Unit (SIU) and Fraud, Waste, and Abuse (FWA) investigations as related to Medicare compliance.
- Respond to CMS requests and audits.
- Support other efforts of the PHP Medicare Compliance Department as required.
Job Requirements General Requirements• Demonstrates knowledge and maintains and respects patient right to privacy by following the HIPAA Privacy and Security policies and procedures. • Adheres to ICARE values and standards of behavior (Innovation, Compassion, Accountability, Respect, Excellence). • Role model behaviors that value the diversity of our associates, patients and customers and supports creating an environment that is inclusive, welcoming and respectful. • Communicates with patients, families and customers using AIDET (Acknowledge, Introduce, Duration, Explanation, Thank). Works in a safe manner and promptly reports any hazards identified in the work environment or related to assigned responsibilities. Work Experience• Minimum of 2 years of other forms of medical/clinical documentation, generally accepted audit principles, coding, including ICD--CM, CPT, HCPCS and medical terminology, billing claim forms including UB-92, HCFA 1500, and charging/billing procedures. • Minimum of 2 years auditing experience in varying aspects of healthcare including but not limited to hospital, outpatient surgical and physician/provider office setting. • Experience in Medicare compliance and insurance plan. Preferred. • Experience in Fraud and Abuse program. Preferred. Education• Bachelor's degree in health related field (nursing, medical records, etc.) or High School Diploma and Certification as RHIT, RHIA or CPC with at least four years experience in health care auditing and coding. • Certification as RHIT, RHIA, CPC or current license as LPN or RN, in good standing. Preferred. Specialized Knowledge and Skills• Must possess strong research and analysis techniques in conjunction with a strong coding/billing background, • Strong computer skills, including all Microsoft Office products and • Strong written and verbal communication skills. • Knowledge of Medicare/CMS regulations and Medicare Advantage programs requirements. Preferred.
Remote work available for this position.
Sparrow Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.Job Family Management/Professional Requirements: Shift Days Degree Type / Education Level Bachelor's Status Full-time Facility Physicians Health Plan Experience Level 4-9 Years
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