Under the direct supervision of the Physician Compliance Manager, this position is responsible for supporting the work plan and compliance functions of the Division of Physician Compliance of the Office of Compliance Services. The responsibilities include:
· Maintains work plan defined auditing & monitoring activity in coordination with the other staff of this division by
1) Conducts research work in preparation for the audit,
2) Review and analyze provider documentation,
3) Prepare reports,
4) Perform necessary post audit training and education,
5) Provide any necessary follow-up reviews and
6) Maintains work documents of activity.
· Serves as a resource for the clients of the Office of Compliance Service to answer compliance questions related to billing and coding of professional services across a broad spectrum of medical specialties that have diverse criteria for billing and coding
· Answers compliance questions from Internal Audit and Audit Advisory Services and assists as necessary in their audit process
· Provides scheduled and ad hoc training for the client of the Compliance Office.
· Conducts and assists with focused reviews as deemed necessary includes assist in determining the scope of the review, the necessary sample size based on the issue in question and the necessary documentation to obtain for the review
· Conducts and assists with compliance investigations includes providing input in to the scope of the investigation, the necessary documentation to gather, participating in interviews, maintaining appropriate work papers and drafting the investigation report.
· Assists the Hospital Compliance Services division of the Compliance Office with the reviews and investigations they conduct as needed
· Conducts research on and prepares analysis of coding and billing compliance issues.
· Prepares guidance materials, monitoring tools and creates resources to assist the Office of Compliance Services and its clients in maintaining an effective Compliance Program
· Assists with the review and revision of existing compliance policies and procedures as well as drafting new policies and procedures as needed.
· Maintains confidentiality of participants involved in investigations, reviews and audits as well as patient information included in such activity.
· Other duties as assigned
ADMINISTRATIVE DUTIES -
Conduct Compliance Reviews
o Complete compliance reviews within established parameters, initiate, and carry out all assigned reviews according to defined departmental policies and processes.
o Perform independent reviews of various Health System operations and other functions to determine compliance with applicable statutes, laws, rules regulations, and policies.
o Analyze and evaluate the quality and adequacy of medical record documentation by UCLA Health System providers in support of claims submitted to governmental and other third party payers.
o Analyze and assess the existence and quality of medical record documentation in support of claims for teaching physician services
o Analyze and evaluate the accuracy and completeness of CPT and ICD-10 coding practices by UCLA Health System providers in support of claims submitted to governmental and other third party payers.
o Analyze and assess the accuracy and completeness of place of service and date of service documentation in the corresponding medical records and claims submitted to governmental and other third party payers.
o Validate payments received for professional services rendered are accurate and consistent with related contractual guidelines and fee schedules of governmental and other third party payers.
o Continually monitor work assignments for proper timing and completion to help ensure the review schedule is maintained.
o Prepare review findings and as necessary explain those findings to the provider and other parties
o Conduct focused reviews in a timely manner and with consistently accurate results.
o Assist the Hospital Compliance Services division of the Compliance Office with reviews as needed.
o When appropriate, participate in external audits/reviews by outside regulatory or law enforcement agencies.
Training and Development
o Provide compliance training as necessary based on the findings of compliance reviews, goals and objectives may change throughout the year depending upon identified needs therefore flexibility, efficiency, and the ability to work independently are required.
o Provide compliance education and training to UCLA Health System physicians, residents, fellows, nurses and other appropriate personnel for both scheduled and ad hoc requests.
o Provide direct training in support of continued adherence to the UCLA Health System Code of Conduct, Professional Fee Billing Compliance Plan and associated policies and procedures.
o Represent the Compliance Office at Enterprise/Department/Division meetings, outside educational programs and in-service trainings.
o Maintain professional certification education requirements to enhance personal growth.
o When appropriate, support the development or revision education and training materials related to billing, coding and documentation practices and other compliance obligations.
o Conduct and support Compliance investigations; includes defining scope of the investigation, identifies and compiles the necessary documentation to gather, participate in interviews, maintain appropriate work papers and draft investigation report.
o As necessary, conduct or participate in investigations directed by the Compliance Office.
o Assist the Hospital Compliance Services division of the Compliance Office with investigations as needed.
o When appropriate, participate in investigations by outside regulatory or law enforcement agencies.
Provide other compliance services to the Compliance Office clients
o Serve as a resource for the clients of the Compliance Office to answer compliance questions related to billing and coding for professional services across a broad spectrum of medical specialties that have diverse criteria for billing and coding
o Prepare guidance documents, monitoring tools, create resources and tools to assist the Compliance Office and its clients in maintaining an effective Compliance Program
o Conduct research on and prepare analysis of coding and billing compliance issues.
o Answer compliance questions from Internal Audit and Audit Advisory Services and assist as necessary in their audit process.
Administrative and other operational duties
o Continually maintain tracking of work issues and assignments in the internal Compliance Database module and ensure the accuracy and quality of the Compliance Database for review by the Deputy Compliance Officer and for review and report generation by the Compliance Office
o When appropriate, participate in departmental strategic and operational planning.
o Maintain thorough and concise documentation throughout audits and/or investigations with dates, times, names and specific details.
o Develop and maintain documentation in support of the audit and monitoring program in accordance with Record Retention requirements.
o Respond to external inquiries seeking regulatory guidance and analysis as assigned.
o When appropriate, participate in applicable continuing education, interactions with enterprise-wide business units and external agencies and in UC-wide compliance activities
UCLA C-I-CARE/Patient Experience Practices: MY COMMITMENT TO CARE
o Observe and practice all the Service Standards listed in the "World Class Practices" (which I have read and signed).
o Practice C-I-CARE when interacting with patients, their families, visitors, or internal customers.
o Connect with the patient and family members by addressing them as Mr./Ms., or by the name that they prefer.
o Introduce yourself and your role.
o Communicate what you are going to do, how long it is going to take, and how it will impact the patient.
o Ask and anticipate patient and/or family needs, questions or concerns.
o Respond to patient and/or family questions and requests with immediacy.
o Exit courteously and/or with an explanation of what will come next (or when you will be back to check on them).
o Practice C-I-CARE phone etiquette during all phone interactions
o Always exercise courtesy whenever patients, family members, visitors and co-workers are present.
a. Respect privacy and dignity of our patients, family members, visitors and co-workers.
b. Maintain professionalism in the presence of patients, their families, visitors and co-workers
o Observe departmental Patient Experience plan, competencies and practices.
a. Act as a role model, verbally and behaviorally demonstrating skill, enthusiasm, positive problem solving, commitment and loyalty to the profession and the organization.
b. Participate in positive problem solving by providing suggestions and possible solutions to identified concerns/problems in the work place.
o Comply with Health System Workplace Conduct Policy
a. Engaging in disruptive behaviors that interfere with or prevent normal work functions or compromise patient safety, including passive or active behaviors will not be tolerated as stated in the HS Workplace Conduct Policy.
o Comply with Health System Dress Code Policy and practices
Bachelor's degree in a related field from an accredited institution or equivalent credentials.
Certification as CHC, CPC or CCS-P or CCS.
Demonstrated expertise in medical terminology.
Demonstrated expertise in healthcare coding (CPT, ICD-10, DRG, HCPCS).
Three years of experience at least two of which must be in a similar position in an academic medical center environment with emphasis on professional compliance activities, including but not limited to: auditing, monitoring, investigation and training,
Demonstrated knowledge and understanding of federal and state statutes, laws, rules and regulations
Location/Region: Westwood, CA