Performs objective audits and/or reviews of Health Ministries (HM) in support of an effective compliance program. As a technical resource, serves the HMs for questions related to health record documentation, coding, billing, and general regulatory compliance. Works on special compliance related projects, assists in disseminating information and providing education to the HM and System Office departments while also assisting with the development of audit tools, job aids and educational programs used to maintain compliance with regulations.Essential Functions
Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions.
Work Focus: Researches, collects & analyzes information. Identifies opportunities, develops solutions, & leads through resolution. Collaborates on performance improvement activities as indicated by outcomes in program efficiency & patient experience. Responsible for distribution of analytical reports.
Process Focus: Utilizes multiple system applications to perform medical record reviews, coding & billing analysis, to create reports & develop educational materials. Incorporates basic knowledge of TH policies, practices & processes to ensure quality, confidentiality, & safety are prioritized. Demonstrates knowledge of departmental processes, procedures, & ability to readily acquire new knowledge.
Data Management & Analysis: Researches & compiles information to support ad-hoc operational projects & initiatives. Synthesizes & analyzes data & provides detailed summaries including graphical data presentations illustrating trends & recommending practical options or solutions while considering the impact on business strategy & supporting leadership decision making. Leverages program & operational data & measurements to define & demonstrate progress, ROI & impacts.
Maintains a working knowledge of applicable federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines in order to ensure adherence in a manner that reflects safe, honest, ethical & professional behavior & safe work practices.
Minimum Qualifications
Bachelor’s degree in a health care related field, or an equivalent combination of education & clinical reviews/coding/billing experience.
Minimum of three years of experience including clinical documentation & coding reviews. Must possess working knowledge of Medicare & third-party payer regulations and demonstrated knowledge & understanding of the laws & regulations impacting the health care provider industry, specifically health care corporate compliance programs & relevant knowledge in areas like revenue cycle, coding & billing, physician financial relationships, conflicts of interest and/or clinical research. Must possess detailed knowledge of federal, state & local laws & regulations impacting health care corporate compliance programs.
Must possess in-depth knowledge of CPT, HCPCS, ICD-10-CM & ICD-10-PCS coding & billing regulations required. AHIMA, AAPC, or equivalent certification required, e.g., Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Health Information Technologist (RHIT), or Registered Health Information Administrator (RHIA).
Certification in Healthcare Compliance (“CHC”) designation or willingness to obtain certification within two (2) years of hire.
Must possess a thorough understanding & knowledge of health care legal & regulatory practices, financial & internal control systems/procedures. Must understand and have in depth knowledge of Hospital Outpatient Prospective Payment System, Inpatient Prospective Payment System, Medicare Physician Fee Schedule, Inpatient Psychiatric Prospective Payment System, Ambulatory Surgery Center Payment System, Provider-Based requirements, EMTALA, Price Transparency & No Surprises Act regulations. Must have extensive knowledge in the guidance outlined in the Medicare Claims Processing Manual, Medicare Program Integrity Manual, & National Correct Coding Initiative (NCCI) Policy Manual.
Additional Qualifications (nice to have)
Possess & maintain licensure or certification in compliance, law, audit, privacy, healthcare, or other relevant field or area of study. Experience with government audits, inquiries, investigations, response, & mitigation.
Experience supporting compliance program operations such as policy management, training & education programs, & investigations preferred.
Master's or professional degree in law, business or health care.
Physical and Mental Requirements & Working Conditions
Direct Healthcare Services / Indirect Healthcare / Support Services:
Exposure to conditions which may be considered unpleasant to sight, touch, sound & / or smell. Occasional exposure to fumes, odors, dusts, mists & gases, biohazards / hazards (mechanical, electrical, burns, chemicals, radiation, sharp objects, etc.). Occasional Exposure to or subject to noise, infectious waste, diseases & conditions. Occasional Exposure to interruptions, shifting priorities & stressful situations. Frequent Ability to follow tasks through to completion, understand & relate to complex ideas / concepts, remember multiple tasks & regimens over long periods of time & work on concurrent tasks / projects. Frequent Ability to read small print, hear sounds & voice / speech patterns, give / receive instructions & other verbal communications (in-person & / or over the phone / computer / device / equipment assigned) with some background noise. Frequent
Perform manual dexterity activities & / or grasping / handling.
Ability to climb, kneel, crouch & / or operate foot controls. Use a computer / other technology. Sit with the ability to vary / adjust physical position or activity. Maintain a safe working environment & use available personal protective equipment (PPE). Comply with Trinity Health’s Code of Conduct, policies, procedures & guidelines.
Ability to provide assistance in the event of an emergency. Occasional
Direct Healthcare Services:
Perform activities that require standing / walking with the ability to vary / adjust physical position or activity. Frequent
Lift a maximum of 30 pounds unassisted. Occasional
Use upper & lower extremities, engage in bending / stooping / reaching & pushing / pulling. Occasional
Work indoors (subject to travel requirements) under temperature-controlled & well-lit conditions. Continuous
Encounter worksites (e.g., patient homes) or travel to worksites that may have variable internal & external environmental conditions. Continuous
Perform work that involves physical efforts (e.g., transporting, moving, positioning & / or ambulating patients). Occasional
Indirect Healthcare / Support Services:
Perform activities that require standing / walking with the ability to vary / adjust physical position or activity. Frequent
Lift a maximum of 30 pounds unassisted. Occasional
Experience of long periods of walking / standing / stooping / bending / pulling & / or pushing. Occasional
Encounter a clinical / patient facing / hands on interactive work environment. Occasional
Work indoors (subject to travel requirements) under temperature-controlled & well-lit conditions. Continuous
Work outdoors with variable external environmental conditions. Occasional
Average Workday Activity: Occasional - O (1% - 33%), Frequent - F (34% - 66%), Continuous - C (67% - 100%)
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.