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Clinical Compliance Auditor Job
Job Number: LCS14187
Job Title: Clinical Compliance Auditor
Department: Internal Auditing - 0014910
Facility: Corporate Headquarters
Location: Providence, RI
Bachelor’s degree in health science profession, preferably nursing; a Master’s degree in a relevant field is a plus. If degree is in nursing, current licensure to practice as a Registered Nurse in the State of Rhode Island or in another state that participates in the Nurse Licensure Compact. Additional consideration would be given for CPC, CCS-P certifications and Epic experience.
Three years recent, professional-level, direct patient care or patient care management experience in an acute care setting to have demonstrated extensive knowledge of general medical or nursing practice and the contemporary methods used to document same. A minimum of one to two years of audit/compliance experience is desirable, preferably with a healthcare organization or third party payer. One year on-the-job experience in order to gain specific knowledge of federal and state regulatory issues relating to healthcare, and to become familiar with the full range of auditing activities. Compliance experience preferred. In-depth understanding of the structure and objectives of a healthcare compliance program. Basic knowledge of standard medical/nursing practice and diagnosis-specific treatment protocols. General knowledge of third party reimbursement policies sufficient to compare details of diagnosis, prescription, treatment and evaluation of documentation necessary to obtain appropriate reimbursement for patient care services. Knowledge of HCPCS and APC Coding methodologies, as well as, Medicare/Medicaid regulatory guidance. Strong analytical, organizational and communication skills are required. Computer skills required are MS Word, Excel, MS Outlook and general database experience; knowledge of personal computer software applications that interface with various billing databases is desirable. Demonstrated written and oral communication skills, planning skills, problem solving skills and project management skills.
The Auditor (Clinical Compliance) reports to the Corporate Compliance Director. Under general supervision, assists in executing various portions of the Lifespan Compliance Plan. Develops and provides compliance training to employee and physician staff. Conducts retrospective audits of itemized patient bills and medical record documentation to assess billing, coding, patient care and compliance with Lifespan general and specific policies and federal and state regulations. May participate in compliance investigations in those areas of risk identified by federal and state regulators. Provides a written summary of work, where problems are found make recommendations to correct. Serves as a resource to other departmental staff on special investigations/projects dealing with clinical matters. Provides functional guidance and direction to less experienced clinical compliance audit staff.