COMPLIANCE SPECIALIST - RISK ADJUSTMENT

PRMO: , established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke PrimaryCare. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke's reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.

General Description of the Job Class

Implement and maintain Coding Compliance programs in accordance with the Office of Inspector General's work plan, to reduce institutional and individual provider legal and financial risk through internal audits, training and education. Additionally increase revenue, accuracy of payment and quality of care with improved documentation by identifying, training/educating, capturing and submitting valid medical diagnosis

Duties and Responsibilities of this Level

70%

• Thorough understanding of clinic coding (E/M) documentation requirements and HCC concepts impacting population Health Risk Adjustment reimbursement initiatives
• Ability to review documentation and abstract all codes with specific emphasis on identifying the most accurate severity of illness according to CMS HCC guidelines
  • Leverage Healthcare Effectiveness Data and Information Set (HEDIS) to measure provider performance on important aspects of care and service
  • Collaborate with CDI Representative to provide timely feedback that will assist with validating and reporting appropriate measures of accuracy
• Offers recommendations and develops templates and tips for capturing the HCCs at the patient encounter
• Serve as HCC subject matter expert in conjunction with CDIS program lead(s) to providers, practice managers, PRMO leadership, and Duke Health stakeholders
• Coordinate activities related to Coding Quality Assurance/Audit. Be actively engaged in coding, abstracting and medical data research to include review and analysis of data input, processing and data output activities.
  • Develop and present educational training programs to hospital and medical coding staff, and maintaining educational collaborations such as Bulletin Review from Payers and review of coding queries.
• Conducts both random and focused reviews on a regularly scheduled timeframe for accurate documentation and coding which is then reported to coding operations.
• Identifies coding and billing risk areas and communicates timely through the appropriate channels/forums those areas that require escalation.
• Collaborates with internal staff in development of improved capabilities in coding and compliance.
• Responds promptly to external and internal concerns with regard to correct coding policies. Identifies errors on claims and sends to the Claim Correction Department for processing.
• Assists with education of providers in regard to compliance and government regulations with special attention to CMS and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and Fraud and Abuse with periodic updates.
• Maintains knowledge regarding policies and procedures with Medicare/Medicaid Carriers and third party payers; including HCC and RAF guidelines
• Collaborates with Internal Compliance Department to promote excellence in correct documentation and coding.

• Interacts effectively and professionally with colleagues to provide helpful information in response to inquiries, concerns and requests.
• Develops and maintains strong working relationships with both internal and external customers.

20%

• Provides documented education ( e.g. PPT, handouts, training materials, etc. to be posted to the Quality Audit/Review Share Point).
• Presents 4 - 7 education sessions each year with evaluations
• Assists in the financial goals of the department through individual efforts as well as encouraging excellence in others via collaboration.
• Adheres to all internal policies.
• Actively promotes a better DUHS work environment and a positive atmosphere in which to work.
• Exemplifies DUHS core values and encourages others to follow this high standard.
• Shows respect and values others at all times.
• Participates in multiple employee engagements that align with covenant mission

10%

• Performs other duties as assigned by management

Perform other related duties incidental to the work described herein:

• Maintains all coding credentialing for I-10, HCC and other training and education.
• May participate in payer testing
• May work with HLI staff and DUHS IT staff to provide data analysis
• May work collaboratively with IMO/MC teams to identify critical language/coding needs.
• Anticipates needs of DUHS regarding I-10/I11 data analytics, preference list and mappings/crosswalks

Required Qualifications at this Level

Distinguishing Characteristics of this Level

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas--an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.