Compliance Analyst RMG

Job Title

Newport News, Virginia

Hiring Range: $57,100.00 - $78,550.00/Annual. Actual pay is determined based on job-related factors such as relevant experience, education, credentials, skills, internal equity, and business needs.

This position is remote work eligible for candidates residing in the following states: FL, GA, ID, KS, KY, MS, NC, OK, SC, SD, TN, VA.

Overview

Primary responsibility is to independently perform clinical chart reviews, risk adjustment audits, payor audits, coding analysis, charge/reimbursement analysis, medical records reviews, and educate provider personnel on coding methodologies that will result in improved accuracy by following RMG compliance standards for commercial and government payors. This position serves as subject matter expert to coordinate review and root cause analysis of coding follow-up/denial and audit work queues, coding denial volumes, and coding trends. Responsible for identifying and reporting obstacles, patterns, and variations as well as resolutions in a timely, clear and concise manner. Serves as an expert for all coding-related questions and is responsible for providing educational materials to answer questions from clinical/office managers, providers and other administrative personnel.

What You Will Do

Independently conducts medical record audits following official coding guidelines and interprets and applies federal and state regulations, coding and billing requirements for baseline, annual, post education and focused provider chart reviews. Analyzes provider coding and documentation to evaluate risks relating to future payor recovery audits. Uses expertise and discretion to apply necessary corrections to ensure compliance with payor rules and regulations with appropriate databases.

Demonstrates expertise and ensures that all third party payor reviews are completed timely with all requested supporting documentation (e.g. medical records). Researches payor rules (e.g. manuals, policies and other sources) for support and guidance. Pre-reviews files and materials and provides summary of findings so that issues can be shared with the department director. Works in alliance with RHS internal auditing. Reports and tracks necessary corrections to ensure compliance with payor rules and regulations with appropriate databases.

Analyzes coding related to 1) ensuring work queues are worked timely and accurately and reporting concerns to department managers, and/or director, 2) identifying trends, 3) conducting root cause analysis of trends, and 4) developing action plans for corrective action. Makes recommendations to manager and practices/departments, including patient accounting (CBO), physicians and contracting to resolve the denied claims and provide education to reduce future denials.

Audits both aggregate coded data and individual encounter data to independently determine opportunities for education, training and documentation improvement for both individual providers and RMG coding team. Provides feedback and suggestions to providers/coders regarding coding accuracy. Identifies trends and opportunities for improvement in clinical documentation and reports this information to the director.

Works with newly hired team members' orientation program to ensure understanding of office based payor regulations (ABN, HIPAA, incident to/shared visits). Oversees the department's new team member and reports on evaluation results with any recommendations as needed. Assists with and/or provides suggestions for continuing education topics and issues for coding staff. Interacts with and educates coding staff in specialty topics. Develops and maintains all presentations and tracking logs.

Works collaboratively with both internal and other departments with assistance and guidance. Answers questions and solves complex coding problems which includes performing preliminary research on topics such as coverage determinations, coding guidelines or standards of care with an emphasis on improving efficiency.

Qualifications

Education:

• High school diploma or GED, (required)

Experience:

• 3-4 years commercial and government billing/coding/collections (required)
• 1 year medical record reviews (required)

Licenses and certifications:

• Certified professional coder (CPC) - American academy of professional coders (AAPC) (required) or
• Certified outpatient coder (COC) - American academy of professional coders (AAPC) (required) and
• Certified professional medical auditor (CPMA) - American academy of professional coders (AAPC) or another AAPC recognized credential, or billing within 1 year (required)