Clinical Compliance Auditor

Under the supervision and management of the Manager of Compliance Audit, the position of Clinical Compliance Auditor (CCA), serves a crucial role in combating fraud, waste, and abuse among all federal healthcare programs (e.g., Medicare, Medicaid, Tricare). The CCA performs compliance audits and investigations with a primary focus on clinical practices, documentation, and behaviors across the Piedmont Healthcare system in order to assess compliance with all applicable federal and state healthcare laws and regulations. Work involves actively directing and conducting compliance audits, investigations, corrective action plans, regulation research, and staff education; providing key contributions to the development of the annual Regulatory Compliance and Privacy Work Plan. This position maintains and promotes all organizational and professional ethical standards.

ADDITIONAL QUALIFICATIONS:
• Possession of one (1) or more of the following certifications or licenses: CFE, CHC, CPA, CPC, or CPMA.
• Excellent chart review skills and ability to target relevant clinical data from a medical record.
• Epic experience preferred.
• Acute hospital utilization review experience with application of the two-midnight rule, InterQual and/or MCG criteria.
• Strong knowledge of Local and National Coverage Determinations.
• Strong knowledge of medical coding, case management, government agencies and contracted payers such as the RAC, MAC, DOJ, OIG, OCR.

KEY RESPONSIBILITIES:
1. Work as a team member to review medical documentation and records from a clinical perspective for potential fraud, waste and abuse (FWA) and to identify trends in provider behavior and billing patterns, including potential overpayments.
2. Research applicable regulations, policy manuals, Medicare guidance, etc. as needed to conduct audits and/or provide guidance to department and operational leaders.
3. Review and analyze patient medical records and related documentation to perform proactive audits and/or participate in reactive investigations.
4. Analyze extracted critical clinical information related to audit topic.
5. Document concise, thorough, and fact-based executive summaries.
6. Develop corrective action plans related to identified deficiencies in collaboration with application department and operational leaders.
7. Liaise with relevant stakeholders to ensure audit findings are remediated and corrective action plans are completed.
8. Create educational material as needs are identified based on audit results.
9. Communicate executive summaries, associated risks, corrective action plans and educational materials with all levels of management and staff, as needed.
10. Conduct investigations, interviews, reviews documents, and summarizes and documents key issues and ability to communicate results effectively to front-line staff to senior leaders.
11. Adhere at all times to compliance policies and procedures.
12. Protect and maintain confidentiality of patient health information and audit documentation.
13. Maintain discretion, professional demeanor and appearance at all times.
14. Report to the Chief Compliance Officer on any suspect violations of law, regulations or noncompliance
to Company policy and take responsibility to ensure resolution.
15. Adhere at all times to compliance policies and procedures.
16. Maintain discretion, professional demeanor and appearance at all times.
17. Complete other projects as assigned.

KNOWLEDGE, SKILLS, ABILITIES
• Excellent chart review skills and ability to target relevant clinical data from a medical record.
• Strong knowledge of Local and National Coverage Determinations.
• Strong knowledge of medical coding, case management, government agencies and contracted payers such as the RAC, MAC, DOJ, OIG, OCR.
 

Qualifications:

MINIMUM EDUCATION REQUIRED:
Bachelor’s degree in Nursing.

MINIMUM EXPERIENCE REQUIRED:
Five (5) years of clinical experience and at least one (1) year of healthcare regulatory compliance experience.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Registered Nurse in the State of Georgia or hold a privilege to practice in the State of Georgia under the
Enhanced Nurse Licensure Compact (eNLC).

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Benefits: