Description

Nuvance Health has a network of 7 hospitals and multiple outpatient locations in the states of Connecticut and New York. In addition we have multiple primary and specialty care physician practices locations. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations.

Summary:

Reporting to the Special Associate Compliance Officer (SACO) Physician Audit & Billing, the Senior Inpatient Professional Auditor provides Hospital Inpatient and Outpatient coding, billing, and documentation auditing and education to the NUVANCE HEALTH network. Effectively interacts with, all departments and different levels of management across the Nuvance Health network.

Responsibilities:

1. Under the leadership of the SACO, conduct high volume of coding compliance audits across all Nuvance Hospitals in accordance with the Department Work Plan and other audits identified by Compliance Management; Review documentation and coding to ensure compliance with all Federal and State guidelines. Ensure correct DRG and APC assignments for Institutional claims.

1. Maintain confidentiality of protected health information and other forms of confidential information as required under (i) applicable Federal and State law including, without limitation, HIPAA and New York and Connecticut patient and personal/private information confidentiality laws, respectively; and (ii) Nuvance Health policies and procedures.

1. Provide comprehensive guidance regarding proper coding and documentation practices consistent with Nuvance Health policies and best practices, and all coding, Federal and State regulatory, and reimbursement guidelines maintaining compliance.

1. Assist with development, updating, maintenance, and disseminating training and education materials to Nuvance Health clinicians, managers, and coding department staff. Provide material and conduct presentations for Compliance education programs as needed. 

1. Communicate and reinforce proper documentation, coding and billing rules and regulations consistent with Nuvance Health policies, i.e., Center for Medicare & Medicaid Services (CMS), American Medical Association (AMA), American Health Information Management Association (AHIMA), to ensure appropriate Current Procedural Terminology (CPT), ICD-9-Clinical Modification (CM), ICD-10-Clinical Modification (CM), Healthcare Common procedure Coding System (HCPCS) and ICD-10-Procedural Classification System (PCS) coding for the Network's Hospital Inpatient and Outpatient coders and services.

1. Perform independent research, assessment and remain current with  CMS, NGS Medicare, and Office of Inspector General (OIG) regulations, guidelines, bulletins, coding practices & methods, annual, semi-annual, and quarterly coding updates and other publications for impact on Institutional services. Monitor daily notifications and listservs such as CMS, Medicare, NGS, AHIMA, etc., and third-party payers for updates and changes in regulations and professional and peer organizations’ practices/policies/guidelines to keep Nuvance Health current with regulatory requirements and accepted compliance and audit practices.

1. Collaborate with the Hospital Coding Department coders to identify errors, patterns, trends, and variances in documentation and coding practices. Document findings utilizing industry compliance standards, and report patterns or concerns to SACO or SCO. Provide recommendations and feedback to SACO or SCO to improve and optimize compliant coding, billing, or documentation practices. Respond to all inquiries in a professional and timely manner.

1. Record and track all DRG and APC compliance audits, assessments, and corrective action plans for Nuvance Health in the compliance tracking logs or vendor-provided databases in accordance with department procedures and audit activity processes. Document and capture timely updates until all corrective action plans are implemented and completed. Perform timely follow-up on outstanding compliance issues; ensure any required changes have occurred to coding, billing, documentation practices, and any associated policies or procedures.

1. Utilize Quarterly PEPPER reports for data mining to identify items for auditing and monitoring efforts to help Nuvance Health identify and prevent payment errors. Communicate the information with Nuvance Health stakeholders in developing Corrective Action Plans where needed.

1. Performs other duties as assigned and in support of the SACO, SCO, and the Nuvance Health Compliance Program.

Education and Experience Requirements:

This position requires a minimum formal education of an Associate Degree required or five + year’s job-related experience in a Compliance Auditing position.

Bachelor’s Degree preferred.

Hospital Inpatient and Outpatient coding experience.

Minimum Knowledge, Skills, and Abilities Requirements:

Must possess a strong body of knowledge in relation to anatomy physiology, medical terminology, and the disease process to be adept in analyzing and assessing medical records, billing records, and other confidential protected health information as necessary to perform compliance duties, function, and role.

Proficient Presentation or education experience.

Extensive coding experience, proficiency in standard coding and billing rules and regulations, CMS, AMA, AHIMA to ensure appropriate CPT, ICD-9-CM, ICD-10-CM, HCPCS ICD-10-PCS coding for the Network's Hospital Inpatient and Outpatient coders and services.

Hospital claim audit experience and knowledge. Excellent and strong verbal and written communication skills.

License, Registration, or Certification Requirements:

RHIT or CCS. Additional certifications or licenses are a plus. Location: Danbury, CT

Department: Corporate Compliance

Exempt: Yes