The Coding Compliance Program Manager is responsible for the development and maintenance of an effective compliance program for medical coding and documentation.
The Coding Compliance Program Manager will prepare independent audit results that evaluate the accuracy of medical coding and documentation by internal coding staff, practitioners, and/or clinical staff. This position will work with the Revenue Cycle Director to assure that all claims and documents submitted to federal, state and commercial payers meet regulatory and private requirements. This individual will assist with data submission to both government and private agencies.
The Coding Compliance Manager maintains and supports a culture of compliance, integrity and ethics; maintains knowledge of policies and procedures and performs in accordance with the organizations Code of Conduct, applicable regulatory requirements, external laws, accreditation standards, and appropriately reports observed fraud or abuse.
Essential Duties and Job Responsibilities –
1. Develop and implement financial, operational, and coding compliance policies, and procedures that support and optimize an efficient revenue cycle
2. Monitor the performance of coding & documentation functions on an ongoing basis against the federal/state laws/rules, third party payers and internal policies
3. Plan & conduct independent investigations, assessments and audits to assess compliance w/ applicable coding/billing requirements and internal policy
4. Obtain, record, and report essential data, assisting in problem solving and ongoing education of clinicians and other staff
5. Work with Administration to identify patterns, trends, and variations in coding and documentation practices as needed
6. Help facilitate investigations, assessments and audits conducted by external agencies
7. Prepare & formally present audit/assessment findings and assist in the development of corrective action plans
8. Record all audits, assessments & corrective action plans in the compliance tracking system and update the system until all corrective action plans are implemented
9. Provide expertise/support for the fraud, waste and abuse detection and prevention program
10. Partner with the Coding staff to develop/implement regular & effective education/training programs for operational employees or clinicians.
11. Develop an effective process for furnishing and disseminating information and guidance on applicable Medicare regulations, state statutes, regulations and federal, state and private payer insurance billing requirements
12. Oversee the implementation of new Medicare, Federal or Billing laws impacting coding and the Revenue Cycle process
13. Participate in a compliance advisory capacity on operational compliance issues
14. Develop and implement an E/M education program for all providers
15. Provide on-going education to the Business Office staff of accurate coding and proper use of modifiers
16. Facilitation of training associated with the implement ICD10
17. Other duties as assigned
Understanding of, and Skills Related to –
• Advanced knowledge of ICD-10, CPT, HCC, and other coding sets
• Experience with developing and implementing training materials and programs
• Experience with statistical sampling and survey methodology
• Experience with audit design, implementation, and practice
• Detailed and current knowledge and experience working with Medicare coding requirements for ambulatory (clinical) and diagnostic services
• Strong understanding of the clinical content of a health record
• Skill in developing, managing, and conducting medical coding education, training, and audit programs
• Extensive knowledge of coding, billing and compliance topics across a broad range of specialties, in addition to knowledge of reimbursement standards
• Ability to adapt to constantly changing priorities in managing a wide range of projects
• Excellent written, communication, and presentation skills with the ability to explain and write complex information in a clear, concise, and organized format
• Ability to work effectively and collaboratively in a team environment
• Proficient in using the following software applications: MS Word, Excel, Powerpoint, Internet and email
• Must maintain all certifications required by the position
• Expert level of knowledge of anatomy and physiology; medical terminology, disease process, reimbursement methodologies; and conventions, rules, guidelines for current coding classification
• Willing and able to work infrequent overtime as required to meet operational needs and perform all duties
• Working knowledge of general office equipment including multi-line phone, computer, copier, calculator and fax machines
• Ability to address and resolve conflict in a professional manner
• Ability and willingness to travel between offices as needed to meet operational needs.
Education and Experience –
• 7+ years of progressive coding experience
• Minimum 5 years’ experience in team building, facilitation/training, and conflict resolution, with demonstrated ability to lead through influence, collaboration and consensus building
• Bachelor’s degree or equivalent experience
• Current certification as a CPC, CCS, CCS-P, RHIA, or RHIT
Other Duties –
• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required for this job. Duties, responsibilities and activities may change at any time with or without notice.