Scope of Job

Responsible for performing compliance reviews of billing and coding compliance functions and activities, compliance risk assessments, developing policies and procedures, and developing risk-based educational training to ensure compliance with federal/state laws and regulations and UTRGV policies. To review and analyze medical records, claims, and workflow processes to ensure accuracy, completeness, and compliance with regulatory requirements.

Description of Duties

• Performs monitoring and compliance reviews of medical billing and coding compliance activities, associated risk assessments, developing policies and procedures and planning and developing risk-based educational training to ensure compliance with federal/state laws and regulations and UTRGV policies.
• Analyses and evaluates the effectiveness of compliance controls used by the area and its compliance with all applicable laws, policies, and procedures.
• Collects information and prepares billing compliance reports, provides supporting evidence, and conclusions, and makes recommendations for corrective measures on identified billing compliance.
• Analyzes data reports to identify issues and risk areas and makes recommendations as needed.
• Collaborates with the medical billing team to improve the quality of clinical documentation for compliance, billing, coding, and reimbursement processes.
• Reviews, assesses and analyzes medical records, coding, billing, claims, reimbursements and workflow processes to ensure accuracy, completeness, and compliance with regulatory requirements.
• Performs charge reviews comparing itemized bills to medical record documents to ensure appropriate charges.
• Performs reviews of electronic and manual documentation, coding, and billing systems.
• Review, assess, study, and analyze the overall coding, billing, documentation, and reimbursement system for potential compliance problems.
• Conducts investigations of non-compliant, alleged breaches of policy to determine the cause and recommend a solution as well as preventative measures.
• Communicates findings to senior management and makes recommendations for preventive measures.
• Coordinates, evaluates and prepares quarterly reporting and verification through inspections and walk-throughs as assigned.
• Responsible for reviewing and preparing appropriate reports for the Physician's Advisory Council, Executive Compliance Committee, and UT System as needed.
• Develops and maintains risk compliance-related education and training materials and conducts training sessions.
• Monitor emerging changes and trends in the law, regulations and industry standards relating to compliance with and enforcement of applicable law and report impactful developments.
• Performs other duties as assigned.