Job Posting: The Senior Manager, Revenue Cycle Compliance develops and directs, in coordination with Cedars-Sinai Health System Corporate Integrity Program, a coding, documentation and data quality compliance program for Cedars-Sinai Medical Network. Responsible to the VP of Revenue Cycle and Managed Care Operations for assuring the key elements of an effective revenue cycle compliance program are in place and operationalized as it relates to the Corporate Integrity Program (e.g., policies, education, risk assessments, profiling, work plan, monitoring, reporting and corrective/remedial actions and daily operations). Establishes system wide coding compliance standards and policies related to documentation and charge capture of professional coding and billing practices. Provides guidance and education designed to promote regulatory charge capture, coding and billing compliance within Cedars-Sinai's Medical Network, Faculty Departments, Enterprise Information Systems and all departments responsible for professional revenue. Provides oversight and guidance to the Managers of PBS Coding and Physician Education to promote documentation and data quality, compliant billing, charging and Revenue Cycle operational practices, as required by Federal and state legal requirements and payer policies. In consultation with the VP, identifies compliance issues, interprets relevant laws, statutes and policies governing compliance issues, and coordinates and/leads projects or policy redesigns to accomplish compliance with the laws applicable to Cedars-Sinai Medical Network. Assures that operations leverages leading practice industry standards and meets all regulatory and compliance requirements. Oversees planning, preparation and presentations of budgets that demonstrates prudent use of the organization's resources while at the same time achieving and maintaining organizational goals and key performance indicators. The goals of the Revenue Cycle Compliance program are to further the Cedars-Sinai Medical Network mission of providing quality health care to our patients, while at the same time, advancing the prevention of fraud, waste and abuse in our health care delivery system. ESSENTIAL JOB DUTIES: Overall Management:
Analyzes reports on, and provides recommendations on corrective action plans, disciplinary actions or compliance issues and risks
Sets long and short range goals, and implements strategies to meet desired objectives.
Monitors clinical and non-clinical documentation is in accordance with Government guidelines to support claims and all applicable regulations including but not limited to: CPT, ICD10 and HCPCs coding and documentation and medical necessity, Physicians at Teaching Hospitals, Billing for Non-Physician Practitioners, Scribes and Locum Tenens. Uses audits and/or other evaluation techniques to monitor compliance and ensure reductions in identified problem areas.
Identifies risk areas associated with coding and billing, including billing for services not rendered; double billing, upcoding, etc.
Ensures documentation of, and updates to, Billing Compliance Standards of Conduct and Policies and Procedures to address compliance issues and areas of risk and fraud.
Stays abreast of all regulatory changes and insures compliance analysts (staff and vendors), PBS and coding vendors managed by PBS are clear on changes.
Creation, management, and communication on changes to interpretation of coding, documentation and billing rules that may not be specifically stated in Government regulations. This is typically referred to as 'the gray'.
Attends, and is directly involved in, any compliance committees and follow-up from committee recommendations
Oversees the development of coding and documentation training materials
Oversees development education and training programs for employees and providers
Provides timely and appropriate responses to inquiries and complaints; develops correction action, including the investigati
At least five (5) or more years' experience working in physician billing compliance in a large, preferably academic institution. Experience with the Compliance Program for Physician Practices from the Office of Inspector General.
5 years' experience in researching complex coding compliance issues and questions, and ability to develop effective education programs for adult learners (coders, physicians, nurses) is required.
Bachelor degree from an accredited college or university required. Master's degree preferred.
Expertise with CPT-4 and ICD-10 coding and medical records documentation
Expertise of procedures and data flow in a health care organization; experience with physician billing preferred Licensure
Certified Procedural Coding – CPC
Certified Coding Specialist – CCS preferred SKILLS AND KNOWLEDGE
Requires and in-depth knowledge of medical terminology, anatomy, physiology, health information computer systems, and documentation requirements for multi-specialty physician practices.
Must be well versed in documentation and coding requirements for professional services and for both inpatient and outpatient hospital and ancillary provider settings.
Requires current knowledge of medical billing procedures and third party payer and Medicare/Medicaid practices and procedures.
Demonstrates excellent communication skills, both verbal and written, and educational skills to instruct Cedars-Sinai Medical Network management, providers, staff, and patients and a high level of interpersonal skills to obtain necessary cooperation and support.
Demonstrates strong leadership skills necessary to handle daily operational activities, analyze situations, make appropriate responses, coordinate resources to meet organizational and departmental needs and supervise assigned team members.
Knowledge of CMS rules and regulations and current coding resources including CPT, ICD-9-CM, ICD-10-CM, HCPCS, fee schedule and HCC's.
Must have a working knowledge of management of an effective ethics and compliance program, including training, monitoring, conducting and documenting investigations, addressing violations and monitoring corrective actions
Should have working knowledge of federal and state reimbursement program requirements (e.g., Medicare and Medi-Cal), federal and state anti-kickback and physician self-referral laws (e.g., Stark and PORA), and provider and practitioner licensure and scope of practice requirements, privacy and consent laws.
Must have demonstrated strong leadership skills, the ability to manage projects across the system is required, including the ability to positively influence other without direct lines of authority to a positive outcome.
Understanding of computer systems, as well as expertise with office based programs such as Word, PowerPoint and Excel. Experience with Electronic Medical Records is required. Experience with Epic is a plus.
Excellent written, verbal and presentation skills in the English language
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scien...tists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.