DescriptionPenn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?Senior Hospital Compliance AnalystJob Summary:
Responsible for the performance and validation of medical record documentation reviews at all hospitals owned by Penn Medicine to assure compliance with applicable federal and state regulations. Incumbent will also participate in performing coding research and other hospital-based audit activity that may be necessary in support of the Department mission.
Other duties include directing a process, in collaboration with hospital departments to include Finance, Revenue Integrity, Information Services and hospital clinical areas, to assure the Charge Description Master (CDM) is current, comprehensive, and compliant with all applicable federal, state, and local regulations.
Participate, as needed, in inpatient audits including Medical Necessity National and Local Coverage Determination focused reviews, and alternative care settings such as Skilled Nursing, Hospice, Home Health, Long Term Acute Care, Pharmacy, Home Infusion. Provides guidance to Compliance Analysts.
Responsibilities:
Responsible for the collection, preparation, assembling and maintenance of data to perform Hospital reviews utilizing internal auditing software.
Direct focused APC audits to assess the adequacy of medical record documentation to ensure that it supports the ICD-10- CM, CPT/HCPCS codes, modifiers and revenue codes billed.
Apply knowledge of Medicare Outpatient Prospective Payment System guidelines to confirm that Penn Medicine receives appropriate reimbursement.
Leads research efforts to analyze external risk and determine focus areas for Compliance annual audit plan.
Performs second level quality assurance APC audits of external coding audit vendors to ensure timely and accurate reporting of results.
Validate technical hospital charges to include Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) and revenue codes contained on the CDM.
Analyze and monitor CDM system-generated reports for the purpose of minimizing risk, optimizing revenue, and enhancing cash flow.
Serve as technical resource to clinical departments resulting in improved documentation of hospital services while limiting external audit risk.
Prepare executive reports for Senior Leadership.
Develop workflows, policies and procedures, and communications related to UPHS CDM activity to enhance organizational practice and efficiencies as identified.
Perform focused documentation reviews in response to internal/external allegations as identified by Senior leadership and Director.
Manage and expedite special reviews, investigations of allegations, focused medical reviews and external audits of all Penn Medicine areas.
Prepares analysis of audit results and generates formal report of findings with recommendations to include complete and corrective action.
Prepare and perform one-on-one and/or group education sessions for hospital or department providers/administration, and/or clinical staff to include development of case studies based upon medical chart examples that emphasize correct coding methodology and revenue risk/opportunities.
Assure government compliance by advising faculty, providers, coders and other appropriate staff of major regulatory changes and coding updates and facilitate risk reduction attributable to chart documentation.
Research and develop materials for the UPHS Billing Compliance website.
Maintains certification.
Performs duties in accordance with Penn Medicine and entity values, policies, and procedures.
Other duties as assigned to support the unit, department, entity, and health system organization.
Credentials:
Certified Coding Specialist (CCS), Certified Procedural Coder (CPC), Certified Outpatient Coder (COC) or Certified Inpatient Coder (CIC) at time of hire (Required).
Education / Experience:
Bachelor's degree, preferably in nursing, HIM or a related field (Required).
5+ years of experience in a related field, e.g., Outpatient Hospital coding, APC analysis, Chargemaster maintenance, billing, and statistical analysis (Required).
Knowledge of medical Terminology (Required).
Course work in human anatomy and physiology (Required).
ICD-10-CM/PCS and CPT/HCPCS coding/billing experience (Required).
Skills & Abilities:
Ability to use Microsoft Word
Ability to use Microsoft Excel
Ability to use Microsoft Power Point
Hospital billing and documentation standards, particularly the Medicare DRG and OPPS/APC payment regulaions
ICD-10-CM/PCS and CPT Manual/CPT Assistant
Knowledge and application of AHA Coding Clinic and Official Coding Guidelines
Appropriate understanding and usage of the CDR (Coder’s Desk Reference)
Familiarity with PA State law website
Familiarity with maneuvering through the CMS website
Familiarity with maneuvering through the Novitas website
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.Live Your Life's WorkWe are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.REQNUMBER: 236564