Senior Compliance Specialist

Senior Compliance Specialist - Stony Brook CPMP Compliance

Location: St. James, NY - This position is eligible for our hybrid work model. This is subject to change at the discretion of management.

Schedule: Full-time

Days/Hours: Monday - Friday; 8:00am - 4:30pm

SUMMARY: The SB Clinical Practice Management Plan, Inc. (CPMP) Senior Compliance Medical Specialist supports the functions of the Compliance Program for CPMP and its University Faculty Practice Corporations to be compliant with Federal and State guidelines in the prevention of fraud, waste, and abuse. The Senior Compliance Medical Specialist will participate and provide duties such as but not limited to conducting auditing and monitoring; providing training and education; assessing compliance with policies, procedures, and regulations; identifying and recommending strategies for process improvements; assessing complex compliance risk-areas to provide input to the annual work plan; participating in investigations; and preparing written reports. The Senior Compliance Medical Specialist performs auditing and monitoring of clinical documentation, analyzing medical records, and assessing the accuracy of ICD-10-CM diagnosis code and CPT assignments; and determining compliance with Federal and State regulations and guidelines. These audits and other projects are identified considering risks identified in State and Federal work plans, industry communications, fraud alerts, regulatory agencies, data mining using software applications, or per management’s request.

Responsibilities and Duties

• Conduct medical record documentation and coding/billing audits assessing the accuracy of CPT codes, diagnoses, and modifier assignments; determining compliance with appropriate policies, procedures, bylaws, clinical staff rules and regulations, and federal and state regulations, and the timeliness of documentation.
• Identify procedural and system weaknesses and offer guidance to physician leaders and management for process improvement.
• Collaborate with colleagues on audits and projects as needed. Produce high-quality work that is competently and efficiently performed in accordance with department standards. Monitor to identify patterns, trends, and variances during and from audits.
• Develop reports from the audit results and/or other sources and assess the need for further review or intervention.
• When requested, prepare comprehensive reports, making recommendations to correct deficiencies and improve processes.
• Participate in the preparation and delivery of compliance education and training programs and remedial education with Providers.
• Conduct follow-up audits as indicated to appraise the adequacy of corrective actions and determine whether deficiencies are corrected; prepare the appropriate reports for management.
• Serve as a coding, documentation, and policy and procedure resource providing regulatory guidance to Providers, employees, and management.
• Research relevant regulations and communicate the need for policies and procedures and education.
• Participate in the design and implementation of a risk-based annual compliance work plan incorporating governmental and other agency regulations and industry alerts, compliance program requirements, and policies and procedures.
• Prepare and present quarterly reports of projects to compliance management.
• Maintain a current working knowledge on regulatory requirements associated with professional coding, billing, documentation, and reporting requirements in an academic medical center and in hospital clinics and physician offices.
• Seek ongoing training and development to gain additional expertise in fulfilling the elements of an effective compliance program.
• Maintain professional skills and knowledge through attendance at relevant educational programs, participation in professional organizations and applicable webinars, and by reviewing current literature.
• Participate in investigations related to compliance helpline calls, inquiries made to the Compliance Department, and unscheduled projects.

Requirements & Qualifications:

• Bachelors' Degree and three years of experience performing professional coding or conducting coding, documentation, and billing audits of professional claims. OR
• Associate’s Degree with five years of experience performing professional coding or conducting coding, documentation, and billing audits of professional claims.
• Must have a current coding certification through the American Academy Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).
• Ability to work collaboratively with physicians, non-physician practitioners, staff and leaders of clinical, financial, and other departments.

Preferred Qualifications:

• Masters' Degree
• Certification in Healthcare Compliance (CHC)
• Experience using MDaudit software

Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to communicate with patients, staff and medical providers. The employee must be able to exchange accurate information in these situations. This position is largely sedentary and requires the employee to remain stationary for a majority of the day. Any additional physical demands will be outlined and provided by management. The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of CPMP.

In accordance with the New York State Department of Health (DOH) order that all hospitals and nursing homes “continuously require all personnel to be fully vaccinated against COVID-19,” Candidates who are not already vaccinated must obtain the first dose of the vaccine within three (3) calendar days of acceptance of conditional job offer and must obtain any subsequent doses in accordance with the vaccine protocol. The order also includes those who may be affiliated with or interact with employees of a hospital or nursing home. The order allows for limited medical exemptions with reasonable accommodations, consistent with applicable law.

CPMP provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity or expression, or any other legally protected status. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall and transfer, leaves of absence, compensation and training.

CPMP expressly prohibits any form of workplace harassment based on race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity, or any other legally protected status. Improper interference with the ability of CPMP’s employees to perform their job duties may result in discipline up to and including discharge.