RN Clinical Compliance Auditor/Analyst

Company: MedStar Health's Washington Hospital Center
Location: Washington
Posted on: April 9, 2025

Job Description:

General Summary of PositionAssists the MedStar Family Choice (MFC) compliance and privacy programs. Conducts both internal and external audits to ensure compliance with regulatory requirements. We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
• Analyzes existing clinical policies and makes recommendations to improve program integrity and organization processes.
• Assists in investigating potential compliance/privacy violations.
• Assists with and tracks responses to external government inquiries, investigations, data requests, subpoenas, and fair hearings. Responds to government requests for claims data/information.
• Assists with internal and external Compliance and HIPAA education initiatives. Conduct provider education, as necessary, regarding audit results.
• Communicates compliance issues and findings identified through audits and reviews. Prepares written audit reports and communicates the results to management. Initiates corrective action plans or continuous improvement plans identified through audits.
• Completes assigned routine and random audits all within assigned time frames. Ensures timely completion of risk assessments and related activities. Maintains or exceeds designated quality and production goals.
• Coordinates monthly exclusion database checks, reviews, and reports findings.
• Maintains compliance tracking systems.
• Maintains confidentiality of all provider and member sensitive information reviewed during the auditing process.
• Organizes and maintains inventory of departmental and delegated vendor compliance and HIPAA policies and procedures.
• Participates in health plan and business unit meetings and serves on system-wide committees as appropriate. Serves as a technical resource in researching and responding to compliance inquiries.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees, and represents the department and hospital/facility in community outreach efforts as appropriate.
• Performs concurrent and retrospective clinical review audits in order to detect potential compliance and/or fraud, waste, and abuse.
• Performs medical record reviews to determine the appropriateness of billing, coding, and documentation.
• Performs other duties as assigned.
• Performs routine and random member and employee audits in order to detect potential compliance issues.
• Performs special projects as requested by management.
• Reports any inquiries concerning improper billing practices or reports of non-compliance to the Director of Medicaid Contract Oversight.
• Reviews and analyzes claims data for trends to identify possible fraud, waste, and abuse. Utilizes audit and monitoring tools to analyze and trend data to identify variances in claims billing.Minimum QualificationsEducation

• Bachelor's degree in Nursing preferred.Experience
  • 3-4 years Clinical experience in an acute care setting; experience in medical record review; 3 years experience in performing internal or external clinical audits and reviews in support of regulatory compliance initiatives required.
  • Experience in health care compliance preferred.Licenses and Certifications
    • RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the jurisdiction of the health plan required.
    • CCS-Certified Coding Specialist At least one coding credential preferred: Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Certified Professional Coder (CPC).Knowledge, Skills, and Abilities
      • Must possess excellent organizational skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously.
      • Strong analytical and attention to detail skills.
      • Ability to work with minimal supervision, guidance, and direction.
      • Knowledge of MS Office (Word, Excel, PowerPoint, and Outlook).
      • Proficient knowledge of Medicaid, Medicare, and other third-party payer requirements pertaining to documentation, coding, billing, and reimbursement.
      • Proficient on performing E/M reviews.
      • Strong knowledge of health care regulations related to reimbursement and coding.
      • Excellent verbal and written communication skills.
      • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
      • Ability to establish and maintain positive and effective work relationships with members, providers, vendors, and co-workers.This position has a hiring range of $72,758 - $130,041.
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Keywords: MedStar Health's Washington Hospital Center, Baltimore , RN Clinical Compliance Auditor/Analyst, Professions , Washington, Maryland