Compliance Resource Specialist

Job Description: The Compliance Resource Specialist (CRS) must have a broad knowledge and understanding of billing compliance as it relates to the Federal and State regulations concerning clinical documentation requirements, billing and reimbursement. Reporting to the Director of Hospital Compliance, the responsibilities include routine clinical documentation monitoring, reviews, education and training as it relates to Part A billing and reimbursement compliance. The CRS is responsible for ensuring that the clinical documentation elements are satisfied for both Federal and State requirements via focused and/or general monitoring, education and training. A. Monitoring Activities 1. Performs monitoring activities on all assigned areas based on risk profiles of the department/institution.2. Notifies the Departmental Chair/ Divisional Chief, and Administrator of scheduled monitoring initiatives.3. Meets with the Administrator or other appropriate staff to discuss specific processes and other information related to billing that maybe unique to that service specialty.4. Analyzes Utilization Billing Report of paid services for each service/physician and determines sample selection for review.5. Performs chart abstraction either retrospectively or concurrently.6. Enters information in the compliance database to generate reports. 7. Performs quality check to ensure accuracy of data.8. Prepares departmental summary report of the monitoring findings for review by the Director of Hospital Compliance or Chief Compliance Officer.9. Presents report to Department Chair/ Divisional chief and other staff as appropriate.10. Prepares an individual analysis report for all physicians monitored.11. Meets with individual physician to discuss analysis report and findings.12. Collaborates with Administrator or other appropriate personnel regarding refund process to third party payer as appropriate.13. Maintains file of all monitoring data for each assigned physician/practice/department. B. Educational Activities 1. When scheduled, will provide clinical documentation and billing compliance education which support the federal and state rules and regulations.2. Provides group or individual provider/physician training based on actual documentation review.3. Provides periodic updates for providers/physicians regarding issues and changes in federal and state regulations, policies and reimbursement.4. As needed or assigned, provides ongoing training regarding billing compliance as it relates to the required clinical documentation elements. C. Resource / Consultation Activities 1. Review with Administrator or other appropriate personnel the requirements and supporting documentation that are needed to comply with ongoing request for or with state and federal audits, and/or other monitoring activities being initiated by federal and or state regulatory agencies to ensure and support billing and clinical documentation compliance. 2. Performs literature search on an ongoing basis to respond to inquiries by physicians and other administrative staff related to billing and other regulatory rules and changes.3. Assists the physicians and administrative staff in the development of documentation templates that would comply with federal and state rules and regulations for clinical documentation and billing compliance.4. Participates in committee activities and special projects as assigned.Job Qualifications: 1. Knowledge of CPT and ICD 9 and current Medicare and Medicaid rules regarding clinical documentation and billing compliance for Part A services.2. Current CPT Certification for Hospital- a must.3. Communication and interpersonal skills to work effectively with a variety of individuals and groups both internally and externally.4. Ability to prepare written reports in a timely manner.5. Ability to use basic data entry and retrieval systems.6. Ability to follow-up on issues and communicate to appropriate personnel.7. Ability to seek opportunities for professional growth and enhancement of current knowledge in billing compliance. BS degree; 5 years of relevant experience.