This position is responsible for a range of compliance, auditing, and monitoring activities. The SIU Investigator will assist with PrimeWest Health’s efforts to ensure compliance with laws, regulations, and policies that govern its Medicare Parts C and D and Medicaid business lines. This individual will initiate investigations and develop cases for future action. This includes referring cases to law enforcement and regulatory authorities, providing education, preventing and recovering overpayment, and performing other administrative actions. The SIU Investigator works with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.
- This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:
- Help Oversee Compliance Program: Aid in the oversight of PrimeWest Health’s Compliance program to ensure program guidelines reflect Centers for Medicare & Medicaid Services’ (CMS) and Minnesota Department of Human Services’ (DHS) interpretation of an effective Compliance program
- Conduct Investigations: Conduct investigations of potential fraud, waste, and abuse (FWA) and improper payments, ensuring compliance with mandatory reporting and other FWA requirements. Conduct compliance risk identification and assessment and audit and monitor for compliance program integrity variances.
Role and Key Responsibilities
- Assist the Corporate Compliance/HIPAA Privacy Officer and PrimeWest Health staff in the following as needed:
- Compliance Program
- Aid in the development and implementation of PrimeWest Health’s Compliance program, actively contributing to and supporting its ongoing effectiveness
Policies and Procedures and Code of Conduct
- Support the development, delivery, and maintenance of the Compliance program and related activities by regularly updating the Code of Conduct and applicable policies and procedures
Auditing, Monitoring, and Oversight
- Apply systematic methodology for analyzing business processes, procedures, and activities with the goal of assessing potential areas of compliance vulnerability and risk
- Conduct investigations into allegations of FWA and non-compliance and provide recommendations for corrective actions. Collect and aggregate data. Provide written analyses, reports, and summary results. Report all findings to the Corporate Compliance/HIPAA Privacy Officer and refer cases to Federal and State agencies, law enforcement, and/or other appropriate professional organizations, as necessary.
- Facilitate the recovery of dollars paid to providers when noncompliance is identified
- Provide input regarding controls for monitoring FWA-related issues
- Develop tools to internally audit programs and test operational policies and procedures against regulatory and claim requirements to reduce organizational risk and detect and prevent improprieties
- Provide expert advice, support, and recommendations to management and staff on a range of complex compliance, audit, and risk management matters, in accordance with established regulatory guidance and PrimeWest Health policy
- Help prepare periodic reports of compliance review findings and corrective actions for review by management, the Compliance and Data Privacy & Security Oversight Committee (CDPSOC), and the Joint Powers Board (JPB)
- Provide support for any other related audit and compliance initiatives and assist in carrying out other related responsibilities
Regulatory Requirements – Contracts
- Maintain comprehensive knowledge of CMS and DHS contracts to ensure compliance with regulatory and contractual requirements
- Research, analyze, and interpret applicable Federal, State, and local laws. Stay current on evolving regulatory requirements.
- Serve as compliance consultant as requested by PrimeWest Health workgroups and committees. Provide consultant services to county agencies and key contracted providers, as requested, to assist with compliance activities.
- Actively participate in organizational quality improvement activities by continually assessing ways to improve performance
General PrimeWest Health Responsibilities
- Abide by the PrimeWest Health Code of Conduct
- Comply with all PrimeWest Health policies and procedures
- Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws
- Be familiar with building safety procedures and alert maintenance if something requires attention
- Keep public areas of the department and office neat and clean
- Conduct other responsibilities and activities as needed and assigned
- Knowledge and understanding of Medicare and Medicaid rules
- Knowledge of healthcare-related compliance requirements
- Experience with investigation procedures
Educational Requirements and Required Qualifications
- A bachelor’s degree in business or other related field is preferred; however, equivalent additional experience in a compliance-related function or medical coding will be considered in lieu of a degree. Experience in health care investigations, encounter data analysis, medical record auditing, provider profiling, and/or claims preparation or examination with a health plan or other health care entity, regulatory agency, government program, and/or internal audit or fraud unit is preferred.
- Knowledge and understanding of common health care claim code sets, including, but not limited to, CPT, HCPCS, and ICD-10
- Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Experience with a claims system is a plus.
- Flexibility and ability to handle multiple tasks at one time
- Demonstrated organizational skills and attention to detail
- Ability to work effectively with a variety of people both within and outside of the organization. Strong verbal and written communication skills and the ability to present complex information clearly and concisely to a diverse spectrum of individuals.
- Experience conducting internal/external audits or compliance reviews is preferred
- Ability to understand and implement healthcare-related compliance guidelines and the ability to analyze, process, and interpret audit results within the constraints for current and anticipated regulatory requirements
- Effective conflict resolution, problem-solving, analytical, and negotiating skills
- Ability to independently research and troubleshoot
- Ability to maintain confidentiality regarding member, provider, and personnel information, as well as other issues that are deemed confidential
- Ability to exercise independent and sound judgment
- Demonstrated project management skills
- Willingness to work hours necessary to successfully accomplish assigned tasks in a timely manner
- Willingness to learn new skills as may be required by the position
- Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 20 pounds. Some travel is required.
PrimeWest Health will accept resumes for this position until filled. Employment to begin as soon as possible.
Source: Hospital Jobs | Recruitology.com