The Coding Compliance Analyst is responsible for collecting, collating, analyzing and interpreting data both internal and external related coding practices. Developing, implementing, and performing compliance related auditing and monitoring activities around potential fraudulent and/or abusive billing and coding practices. The identification, investigation, and correction of fraudulent and/or abusive billing and coding practices; case tracking and coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices. Organize and educated staff coding guidelines, including policy revisions.
Bachelors Related Field
CERTIFICATION & LICENSURE REQUIREMENTS
American Academy of Professional Coders (AAPC) and/or American Health and Information Management Association (AHIMA)
Three (3) years Related Field. Knowledge of accurate physician, facility and DME billing. Experience with data collection and sampling methodology and performing and documenting audits. Experience conducting reviews of medical records and bill coding to ensure provider coding accuracy and during the course of fraud and abuse investigations. Experience in conducting potential compliance coding investigations.
Technical-coding skills required. Knowledge of provider reimbursement methodologies. Applicant must have or obtain all necessary technical coding expertise as it relates to nomenclature of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), DRG, and Internal Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM). Applicant must also be familiar with regulatory guidelines and their application to technical coding. Knowledge of Medicare Parts A and B, Medicare Advantage, Medicare Prescription Drug Benefit regulations. Analytical aptitude with excellent verbal and written communication skills required. Self-motivated and accountable for project coordination and follow-through. Organizational and planning skills required. Must meet deadlines and produce accurate work product. Proficient in Microsoft office products (i.e., Word, Excel, Access, PowerPoint and Outlook).
Performs potential compliance coding investigations. Creates detailed case reports of fraudulent and abusive activities. Submits findings from detailed analysis and makes recommendations to Compliance Officer. Participates in internal SIU Team Meetings.
Analyzes coding/claims data as part of the investigative process using fraud detection software provided by vendor and collaborate with vendor SIU on cases when necessary. Organization and maintenance of coding compliance reports generated from software tool.
Conducts data mining activities, data analysis and reporting using available tools and internal data warehouse.
Collaborates with internal departments on routine internal monitoring of healthcare coding conventions.
Review, interpret, and disseminate federal, state, and industry rules and regulations in regard to coding compliance. Obtains all data needed to assure compliance with regulatory agencies. Keeps current with all standard coding practices, Medicare Advantage Fraud, Waste and Abuse guidelines.
Assists in the development and implementation of organizational measures and policies and procedures to prevent, detect and correct coding compliance issues. Collaborates with senior management and leadership to ensure organization remains in coding compliance. Performs compliance related coding audits as assigned.
Chairs the internal code review committee and organizes and leads topic specific work groups. Chair the external Medicare Update/Transmittals Committee.
Assists with the creation and delivery of formal and informal education related to coding compliance. Participates in meetings as assigned.
Prepares and presents coding compliance reports to the Medical Economics Team (MET).
Reviews organizational Medical Policies to ensure coding compliance.
Reviews all Wellness Program documents and plans to ensure coding compliance.
Full - Time