Senior Consultant - Healthcare Compliance

Overview

BerryDunn is seeking a Senior Consultant to join our Healthcare Group as a member of the Healthcare Compliance Practice Area. You will join a core team tasked with assisting the firm’s clients with clinical documentation improvement, revenue integrity efforts, regulatory research, and general coding and billing compliance in a multitude of healthcare settings. This role involves complex audit reviews, provider education, and data-driven analysis to identify trends, mitigate risk, and optimize revenue integrity. This position is planned to sit remotely. The ideal candidate for this position will possess both a clinical and coding / auditing background with experience in both inpatient DRG/APR-DRG, and professional services CPT and ICD-10 coding.

You Will

• Perform comprehensive audits of facility and outpatient/professional claims for coding accuracy (i.e. CPT, HCPCS, ICD-10-CM/PCS, DRG, APC, and E/M levels)
• Review clinical documentation and coding to ensure compliance with relevant payer policies, as well as applicable Federal and State regulations and coding guidelines.
• Conduct education sessions for physicians and other qualified healthcare practitioners based on results of clinical documentation reviews
• Review billing practices for facilities and practitioners across the continuum of care.
• Perform independent research, assessment and remain current with CMS, NGS Medicare, and Office of Inspector General (OIG) regulations, guidelines, bulletins, coding practices & methods, annual, semi-annual, and quarterly coding updates and other publications for impact on Institutional services. Monitor daily notifications and listservs such as CMS, Medicare, NGS, AHIMA, etc., and third-party payers for updates and changes in regulations and professional and peer organizations/practices/policies/guidelines to keep current with regulatory requirements and accepted compliance and audit practices.
• Analyze paid claims data reports and develop risk informed audit plans.
• Assist with development, review, and maintenance of compliance-related policies, procedures, and workplans.
• Identify, assess, and escalate potential compliance risks, including billing, documentation, privacy, and regulatory concerns.
• Assist clients with regulatory inquiries and payer reviews and participate in special compliance projects (e.g., external audit response, RAC review).
• Analyze large data sets from EMR, billing systems, and audit tools to identify patterns, outliers, and compliance risks.
• Develop dashboards and reports to present audit findings, trends, and actionable insights to leadership and compliance officers.
• Recommend actionable improvements to policies, workflows, and coder/provider performance
• Remain current with changing compliance and audit issues through ongoing education and outreach efforts. 
• Safeguard Protected Health Information (PHI) through adherence to HIPAA privacy and security standards in all documentation and communication
• Perform other duties as assigned.

You Have

Experience (required):

• Minimum 3-years recent experience of MS-DRG, AP-DRG and APR-DRG, professional and outpatient CPT and ICD-10 coding/auditing with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
• Experience in developing and providing audit outcomes to practitioners and staff
• Skilled in applying the official coding guidelines, coding clinic determinations and CMS and other payer and regulatory compliance guidance. Requires expert coding knowledge - DRG, APR-DRG, ICD-10, CPT, HCPCS.
• Demonstrable Proficiency in using Word, Outlook, Excel, and PowerPoint
• Excellent written and verbal communication skills

Qualifications:

• One or more nationally recognized inpatient coding compliance certification (i.e. AHIMA CCS, AAPC CIC) and professional coding certification (i.e. AAPC CPC) required
• Bachelors degree, RN/LPN or other clinical credential, and/or clinical documentation improvement certification preferred
• 3 years’ minimum relevant healthcare experience is required including specialized skills in compliance related activities
• Ability to work independently, as well as in a team setting
• Exceptional flexibility, organization and time management skills to manage priorities and deadlines
• Adeptness in regulatory research related to clinical documentation and compliance

 Technical Skills:

• Prior experience using Electronic Hea