Manager Compliance

POSITION SUMMARY:

• The Manager, Auditing and Monitoring will manage a team of Compliance Auditors/Educators, principally clinicians and certified coders, as well as external audit/education resources, that perform hospital, physician, and allied services billing compliance auditing and monitoring activities for Steward Health Care System (Steward). These compliance audits will focus on evaluating compliance with Steward policies as well as compliance with applicable Medicare, Medicaid, and other third-party guidelines in effect as of the applicable date of service, including identification of lost revenue opportunities and overpayments that need to be refunded due documentation, coding or billing issues.
• This position reports to the Vice President, Compliance and Privacy Officer. The Manager, Auditing and Monitoring need to be a person of high integrity, and any other duties assigned should not conflict with Steward’s compliance program goals and objectives.
• This position will be based remotely and will require travel to Steward locations from time to time.
• This position will be part of a team of Compliance Auditors who perform compliance auditing and monitoring of hospital inpatient and outpatient services as well as other clinics billed to Medicare, Medicaid, and other third-party payors. The compliance audit schedule for this team is based on an annual Compliance Work Plan.
• This position is responsible for driving compliance program “operational excellence” (i.e., standardization, scalability, effectiveness, and efficiency) related to hospital auditing and monitoring system-wide. Furthermore, this position will be responsible for adapting the capability of the team of Compliance Auditors to meet an evolving landscape of regulatory compliance requirements (e.g., ICD-10, etc.).

KEY RESPONSIBILITIES:

• Assists the Vice President, Compliance & Privacy in conducting annual compliance risk assessments and developing annual Work Plans using a risk-based approach to support the overall annual Compliance Plan
• Works collaboratively with the Internal Audit, as appropriate, in performing risk assessments and developing audit plans to avoid any potential duplication of efforts
• Manages and supervises a team of Compliance Auditors/Educators. Management responsibilities include but are not limited to hiring, training, development, and performance management as well as continuous improvement of workflow/communication within the team based on leading practice techniques.
• Assists with the professional development of OCCP staff through in-service meetings, education programs, conferences, etc.
• Manages and supervises external audit/education resources including sample selection, record access, report development as well as overall project management
• Develop and manage ongoing data analytics efforts, based, in part, on the annual Work Plan
• Plans and performs compliance audits based on the annual Work Plan, as amended. Assists in performing other compliance audits or investigations as requested. Produces well-written, accurate draft audit reports for review by the Vice President, Compliance & Privacy on a timely basis
• Schedules meetings with appropriate department managers to discuss audit initiation. Consults with senior management and staff upon the conclusion of audits, both oral and written, to describe observations and recommend corrective action to remediate issues identified and enhance compliance
• Develops policies and procedures for auditing medical records for compliance with required documentation guidelines including completeness and accuracy of coding. Makes recommendations that are consistent with regulatory requirements for coding/billing, to assure that services rendered are documented and claims are being submitted appropriately
• Ensures quality assurance through an internal peer review process on each compliance audit
• Maintains documentation of methods used and individuals involved in verifying compliance; documented identified issues, corrective actions taken, and improvements implemented. Establishes and implements best practices for audit working paper documentation, security, and retention.
• Provides recommendations to improve documentation, coding or billing practices, correct any discrepancies discovered during audits, and prevent reoccurrence
• Assists with the development and delivery of compliance training programs, as assigned
• Ensures that identified issues are logged in the OCCP database accurately and timely
• Assists with preparing written reports, on a quarterly basis or as requested, to keep the SVP, Chief Compliance Officer, and Vice President, Compliance & Privacy informed of compliance activities and issues for assigned areas on a timely basis. Also, assists with providing reports to assigned Steward entity-level management on compliance program activities and issues on a regular basis (at least quarterly)
• Interacts with employees at all levels, always demonstrating impartiality and fairness
• Establishes and retains a cooperative relationship with Medicare Administrative Contractors and others to understand applicable Medicare and other third-party payor requirements
• Demonstrates knowledge and understanding of Steward’s policies and procedures and applicable regulatory requirements. Maintains a library of appropriate reference material that will facilitate the understanding of and compliance with applicable requirements

• Establishes effective working relationships and builds credibility within the Steward hospitals to support a culture of compliance
• Identifies potential risk areas on an ongoing basis and assists the Steward hospitals with developing risk mitigation and/or corrective action plan strategies
• Under the direction of the Vice President, Compliance & Privacy acts as a consultative resource on issues concerning compliance and provides recommendations to enhance policies, procedures, and internal controls as needed
• Disseminates key industry regulator audit updates such as CMS, OIG, etc. to the OCCP team

• Cooperates with the regulators (e.g., CMS, OIG, OCR, State Attorney General, etc.) and other parties, as appropriate, in connection with any privacy or compliance inquiries, audits, or investigations
• Participates in healthcare compliance and coding-related professional organizations to stay abreast of compliance developments and leading industry practices
• Represents the OCCP through participation in various Steward committees and work groups as assigned
• Participates in periodic OCCP team meetings to ensure effective communication
• Maintains time and effort reporting records as assigned

• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment

1. Commits to recognize and respect cultural diversity for all customers (internal and external)

2. Communicates effectively with internal and external customers with respect to differences in cultures, values, beliefs, and ages, utilizing interpreters when needed

• Performs other duties, as assigned, be SVP, Chief Compliance Officer, and VP, Compliance and Privacy

REQUIRED KNOWLEDGE & SKILLS:

• Knowledge and experience with hospital-related health care laws and regulations (e.g., Anti-Kickback Statute, Stark Law, etc.), and hospital inpatient and outpatient coding and billing compliance required
• Familiarity with federal and state privacy laws and regulations required
• Familiarity with operational, financial, and information technology security procedures and regulations is a must
• Strong oral/written communication and presentation skills are a must
• Strong leadership, organizational, interpersonal, and analytical skills and the ability to function effectively in a fast-paced environment
• Ability to prioritize and plan work independently
• Ability to interact with employees at all levels
• Effectively work with and coordinate the activities of external consultants and legal counsel as assigned
• Ability to anticipate potential issues and proactively respond
• Good judgment and problem-solving skills
• Team player
• Ability to maintain confidentiality

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

1. Education: A bachelor’s degree is required.
2. Experience: A minimum of 5 years experience in a healthcare environment including demonstrated management and leadership in hospital billing compliance/auditing.
3. Certification/Licensure: Certified Coding Specialist—Hospital-Based (CCS-H) or Certified Professional Coder (CPC) preferred. Additional specialty coding certifications (e.g., Evaluation and Management, Emergency Department, etc.) are desired. Certification in Healthcare Compliance (CHC) certification is required or must be obtained within one year of hire. Software/Hardware: Microsoft Outlook, Word, Excel, Internet Explorer and PowerPoint Skills Required. Microsoft Access Skills preferred. The ability to effectively navigate electronic health records and hospital billing systems is required. The ability to research applicable Medicare, Medicaid, and other compliance requirements is required.
4. Other: Travel Requirements:

• The ability to travel regionally and nationally
• Must have a valid driver's license, provide own transportation, and be able to travel to Steward locations using a variety of modes of transportation