Compliance Coordinator

The Compliance Coordinator is responsible for maintaining Agency compliance for all service delivery programs. This position uses expertise to resolve claim audits and works in conjunction with the Pre-Bill Auditor to identify and develop process correction to ensure compliant intake to billing practices.  This position will review charts and audit for accuracy and completeness, coordinate workflow with the Pre-Bill Auditor, communicate professionally to applicable staff any findings needing corrective action, and support process development.  This position supports regulatory compliance and QAPI activities, drives best practice policies and procedures to maintain compliance, and organizes internal plans of correction in conjunction with the Director of Quality and Compliance. Serves as the point person for submitting clinical records for ADR and claims appeal processes.

Essential Duties and Responsibilities:

1. Audits front end data elements including but not limited to demographics, insurance information, provider identification information, charge capture, timeline compliance, and LCD completeness for accuracy.

1. Maintains comprehensive working knowledge of government and payer billing regulations in all service lines, including Medicare and Medicaid regulations and third-party insurance carriers, and serves as a resource for appropriate agency personnel.

1. Works in close conjunction with the Pre-Bill Auditor to facilitate initial problem solving related to billing queries between billing and operations. Triages clean claim strategies and problem solves process advancement for best practice in clean claim capture.

1. Maintains responsibility for payer credentialing requests and provides credentialing documentation to payers in a timely manner.

1. Collaborates with appropriate branch staff regarding documentation needs for billing.

1. Maintains confidentiality and adheres to all HIPPA guidelines and regulations.
2. Coordinates information gathering with Billing and Medical Records in the case of additional documentation required appeals. Ensures appropriate Directors have reviewed these appeal packets before submission and follows submission with appeals tracking.

1. Manages the internal compliance report process within PIHC and initiates performance improvement plans in relation to areas of risk found during report processing.

1. Interfaces with the Director of Information Services in performing annual HIPAA risk assessment and coordinating follow through for identified areas of risk.

1. Coordinates activities related to implementation of policies, procedures, and processes to meet and maintain compliance with ACHC accreditation standards. Utilizes research to interpret standards into agency policy, as needed. Ensures HR processes maintain proper employment records required within ACHC standards.

1. In coordination with Program Managers, facilitates progression of quality improvement action plans and reports progress to the Director of Quality and Compliance.

1. Partners with management to prepare for regulatory and accreditation surveys and oversees developing corrective action plans.

1. Gathers and creates material for quarterly presentation at the QI Committee meetings in conjunction with the Director of Quality and Compliance.

1. Performs other duties as assigned by supervisor.

Minimum Qualifications:

• Associate or bachelor’s degree in business administration or similar preferred. May be substituted with experience in the following.
• Qualifications include experience in home health, hospice, HME compliance and/or billing preferred.
• Clinical understanding of delivery of care preferred.
• Comfort level with Excel and creation of simple formulas and graphs.
• Excellent computer skills and ability to self-learn software applications for management of process correction and for presentation/analysis of quality data.

Physical Demands & Working Conditions:

Work is generally performed in the office environment. The position also includes regular use of a keyboard, and use of hands to finger, handle, and feel.  Onsite preferred but position may be performed hybrid/remotely if approved by the Director of Quality and Compliance upon offer.