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Reporting to the Manager, Compliance Audit and Analysis, develops and executes audit, monitoring, and education for inpatient hospital billing, coding and documentation programs that ensure compliance with regulatory standards. Continuously evaluates inpatient hospital/clinical billing compliance activities to assess compliance with the Compliance Audit and Analysis Program and appropriate focus on risk areas. Serves as a resource for providers and caregivers on hospital/clinical billing and coding.

Primary duties and responsibilities:

• Prepares and oversees inpatient hospital/clinical billing and coding components of the Compliance work plan reflecting scheduled activities and target dates. 
• Leads focused audits and reviews to investigate adherence with inpatient hospital/clinical billing compliance policies, legal and regulatory requirements, and to identify and evaluate risk areas.
• Assists in development of organizational compliance auditing and monitoring activities for hospital/clinical billing and coding, including periodic reviews of the individual department auditing and monitoring functions. 
• Coordinates sample reviews to ensure codes that were billed are properly supported by appropriate documentation.
• Creates audit result reports to be reviewed with providers.
• Organizes and schedules audit findings/education sessions with providers to review audit results.
• Conducts trend analyses to identify patterns and variations in inpatient hospital/clinical billing and coding practices that indicate areas of heightened risk.
• Serves as primary lead for inpatient hospital/clinical billing compliance education including auditing, trending, and feedback to hospital inpatient coders and providers working in the hospital setting, as applicable.
• Manage and foster relationships with internal coders and managers and 3rd party clinical reviewers.
• Leads training on proper documentation for inpatient hospital/clinical billing and coding compliance.
• Works with the compliance operations, billing team, senior leaders, and key department stakeholders to ensure training is current, relevant, and innovative. 
• Evaluates training methods and modalities and works with relevant departments to implement.
• Ensures required provider compliance training related to inpatient hospital documentation, coding and billing is completed on time and in accordance with compliance program policies.
• Provides counseling, education and/or recommended disciplinary action if necessary or required for non-compliance with any internal or external policies and procedures related to hospital/clinical billing compliance. 
• Recommends corrective action plans if necessary to address deficiencies identified by auditing and monitoring activities for specific inpatient services, or on an organization-wide basis.
• Conducts audits and manages findings of audits or other reviews in MDAudit, and works with the Manager, Compliance Audit and Analysis, if issues need to be entered into the departments issues tracking modality. 
• Maintains required credentials, participates in continuing education opportunities to remain current with billing and coding compliance best practices (i.e., conferences, workshops, and other professional development activities).
• Maintains confidentiality of patient/members and staff information.
• Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.

Education and experience requirements:

• Bachelors degree required.
• Clinical background preferred (i.e., LPN, RN, etc.).
• Current Certified Coding Specialist (CCS) certification required. Certification in Healthcare Compliance required.
• Minimum of three (3) years of experience with either inpatient or outpatient audit activities, required. 
• Proficient in MDAudit Enterprise software and Epic electronic health record systems.
• Thorough knowledge of coding documentation improvement practices.
• Thorough knowledge and understanding of hospital inpatient billing, coding, and documentation requirements, Federal and State regulations, medical necessity, clinical best practices, and hospital/clinical billing issues. 
• Project management experience preferred.

Knowledge, skills, and ability requirements:

• Knowledge of legal, regulatory, and policy compliance issues related to coding, billing, procedures, and documentation.
• Ability to clearly communicate coding information, including the results of coding compliance audit activities. 
• Proficiency in root cause analysis, critical thinking, and gaining acceptance of recommended solutions.
• Team player and understands role in relationship to others.
• Strong interpersonal and communication skills.
• Clear, concise, and persuasive writing and presentation skills.
• Strong orientation to deadline and detail.
• Strong organizational and project management skills.
• Working knowledge of computer software Word, Access, Excel, PowerPoint; as well as EMR. 
• Knowledge of healthcare financial management principles/practices.
• Ability to work in highly matrixed environments.
• Ability to be flexible and adapt to change.
  
  
  

Supporting a diverse, equitable and inclusive culture.  Emory Healthcare (EHC) is dedicated to providing equal opportunities and access to all individuals regardless of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression and/or veteran's status. EHC does not discriminate on the basis of any factor stated above or prohibited under applicable law. EHC respects, values, and celebrates the unique perspectives and backgrounds of all individuals. EHC aspires to create an environment of collaboration and true belonging for all our patients and team members.  Emory Healthcare (EHC) is committed to achieving a diverse workforce through equal opportunity and nondiscrimination policy in all aspects of employment including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training.

PHYSICAL REQUIREMENTS (Medium Max 25lbs): up to 25 lbs., 0-33% of the work day (occasionally); 11-25 lbs., 34-66% of the workday (frequently); 01-10 lbs., 67-100% of the workday (constantly); Lifting 25 lbs. max; Carrying of objects up to 25 lbs.; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.

ENVIRONMENTAL FACTORS: Factors affecting environmental conditions may vary depending on the assigned work area and tasks. Environmental exposures include but are not limited to: Blood-borne pathogen exposure, Bio-hazardous waste chemicals/gases/fumes/vapors, Communicable diseases, Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.