Clinical Compliance Specialist

RESPONSIBILITIES

1. Examines client’s records for accuracy, compliance, and validity.
2. Assists leadership in conducting compliance risk assessments of our scheduling, billing and coding operations and the implementation of annual work plans to ensure that identified risks are appropriately mitigated.
3. Develops and maintains a current knowledge of scheduling, billing and utilization management policies utilized in the review process.
4. Reviews policies, procedures, documentation standards and identify areas of improvement in clinical documentation based on audit outcomes.
5. Conducts audits of clinical documents and reviews scheduling and billing operations to assess compliance with regulatory requirements.
6. Recommends and discusses areas for remediation opportunities with Leadership team based on audit outcomes.
7. Assists with training of staff as to appropriate scheduling, medical recordkeeping, and billing.
8. Collaborates with Compliance to ensure the implementation of written policies and procedures that reinforce current federal and state statutes, rules, and regulations regarding the submission of claims and Medicare/Medicaid cost reports.
9. Ensures the timely reconciliation of members’ medical records.
10. Researches and identifies best billing practices and methods to ensure maximum revenue generation and cost recovery while maintaining compliance with government regulations.
11. Provides recommendation and advice regarding the use of billing codes.
12. Works with Revenue Cycle Department team to ensure proper clinical documentation before claims submission.
13. Prepares reports as to compliance, unsigned documents, inaccuracies, and/or errors.
14. Partners with the Finance, Quality, Compliance and Revenue Cycle departments with billing and scheduling improvement on audit outcomes.

EDUCATION AND EXPERIENCE

• Bachelor’s degree required; Masters degree preferred
• Valid State of Michigan licensure (i.e., LLMSW, LMSW, RN, LPC, etc.) required.
• Proficiency with Electronic Medical Records systems and Microsoft Excel required.
• Experience in a community-based setting (FQHC or Integrated Care) highly preferred.
• Familiarity with coding and determining level of service.
• Critical thinking and strong problem-solving skills.
• Ability to initiate and maintain positive working relationships with staff and others.
• Must maintain confidentiality in accordance with HIPAA guidelines.
• Ability to formulate decisions and make judgments that are demanding and interpretative.
• 3 - 5 years of recent medical records experience (accuracy, compliance, and validity) required.
• Minimum of three (3) years of leadership/progressive management experience required.
• Advanced knowledge of federal, state, and local health care laws and regulations, particularly Community Mental Health and other federally funded program regulations.