Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.
The Compliance Analyst/Auditor serves as a regulatory clinical specialist within the Office of Compliance and Privacy at SJRMC, to help manage inquiries on a variety of compliance topics by: gathering additional details on the questions/issues and conducting relevant research. The Compliance Analyst/Auditor assists with the ongoing implementation and maintenance of SJRMC’s compliance program efforts; including, but not limited to: policy and procedure development, risk assessment, auditing and monitoring, training and education initiatives, and compliance programmatic developments and enhancements. This position will have a focus on auditing and monitoring, analyzing and reporting trends to identify potential risk areas for review and/or education.
Required Qualifications:
- Bachelor’s degree and RN or other Clinical Degree. Accounting or finance degree with clinical background may be considered.
- Minimum of three (3) years of experience in healthcare clinical compliance or auditing
- Minimum of three (3) years of experience in coding, documentation, billing, and/or reimbursements
- Required experience in healthcare
Preferred Qualifications:
- License, Registration or Certification Required: Certification in Healthcare Compliance (CHC) from the Health Care Compliance Association (HCCA), Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC), Certified Coding Specialist (CCS) by the American Health Information Management Association (AHIMA) or equivalent certifications. Must be obtained within one year.
- Experience in the hospital environment
- Experience and thorough understanding of the False Claims Act
Knowledge, Skills, and Competencies:
- Excellent analytical, problem-solving, and decision-making skills
- Must be detail oriented, take initiative to learn new tasks, and recommend program improvements
- Ability to manage difficult, sensitive, and confidential situations with integrity and professionalism
- Strong interpersonal skills; able to deal effectively with diverse skill sets and personalities
- Highly organized with proven ability to prioritize workload, meet deadlines, and manage several projects at one time
- Possess a high degree of flexibility to respond rapidly to changing goals, ability to work under pressure, and meet deadlines
- Excellent verbal and written communication skills
- Excellent writing, editing, and proofreading skills
- Executes all job responsibilities and assignments promptly, reliably, honestly, and ethically
- Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint), including creating charts and graphs
Duties and Responsibilities:
- Coordinate, monitor, and audit documentation and coding of inpatient and/or outpatient services (in all applicable health care settings). Audits will focus on correct assignment of codes (i.e., CPT, HCPCS, ICD, etc.), review for medical necessity, and clinician documentation (to ensure that SJRMC is compliant with all regulatory guidelines and internal controls).
- Analyze audit results; identify patterns, trends or variations in coding and documentation practices and make recommendations for improvement
- Review and audit coding, billing, and documentation for compliance based on federal regulatory requirements, The Centers for Medicare and Medicaid Services (CMS), LCDS, NCDs, and current documentation and coding guidelines; as well as, ensuring compliance with departmental/internal policies and other applicable laws and regulations
- Prepare audit reports for all findings/observations and provide appropriate recommendations
- Partners with the business units and staff, in coordination with Compliance management; to develop quality improvement and corrective action plans based on audit findings and recommendations
- Performs trend analyses to identify and analyze clinical and compliance patterns/variations in coding practices
- Assist with investigative reports of compliance concerns and/or violations
- Maintains current knowledge of federal and state regulations and guidelines (CMS, OIG, etc.) keeping abreast of current changes that may affect healthcare systems
- All SJRMC employees are responsible for implementing SJRMC’s Service Standards into their activities: Safety, Courtesy, Effectiveness, and Stewardship
