GENERAL SUMMARY

The Clinical Compliance & Audit Specialist is responsible for managing the improvement and completeness of clinical documentation to ensure compliance with the Center for Medicare and Medicaid Services (“CMS”) clinical coverage requirements as well as any other relevant agency or organization’s requirements. This position is also responsible for maintaining expert knowledge of clinical regulatory requirements in order to develop strategies and a plan to build staff competency on requirements related to medical necessity, documentation and coding requirements throughout the Shirley Ryan AbilityLab System of Care.

The Clinical Compliance & Audit Specialist will manage all CMS medical claim audit requests (e.g., Recovery Audit Contractor, Additional Documentation Request, Comprehensive Error Rate Testing) as well as any other required audits, as determined. This position coordinates the disposition of a denied claim, including writing appeal letters and has accountability for daily management, tracking, and communication of all audit and appeal activities.

The Clinical Compliance & Audit Specialist will consistently demonstrate support of the Shirley Ryan AbilityLab Statement of Vision, Mission and Core Values by striving for excellence, contributing to the team efforts and showing respect and compassion for patients and their families, fellow employees, and all others with whom there is contact at or in the interest of the institute.

The Clinical Compliance & Audit Specialist will demonstrate Shirley Ryan AbilityLab Core Attributes: Communication, Accountability, Flexibility/Adaptability, Judgment/Problem Solving, Customer Service and Shirley Ryan AbilityLab Values (Hope, Compassion, Discovery, Collaboration, & Commitment to Excellence) while fulfilling job duties.

PRINCIPAL RESPONSIBILITIES

THE CLINICAL COMPLIANCE & AUDIT SPECIALIST WILL:

1. Responsible for keeping abreast of CMS rehabilitation and therapy requirements and coding guidelines as well as any other relevant guidelines ore regulations.
2. Ensure documentation templates and systems support regulatory requirements in collaboration with physicians and other clinicians.
3. Build staff competency on requirements related to medical necessity, documentation and coding requirements.
4. Conduct routine clinical documentation reviews and provide direct feedback as well as use the aggregate information to educate staff, as necessary, and revise systems, templates, processes, etc.
5. Use clinical knowledge to analyze clinical coverage and coding denials.
6. Daily management, monitoring, tracking, and communication of all audit and appeal activities.
7. Timely write and file appeal letters outlining medical necessity and compliance with coding guidelines.
8. Maintain a database and detailed records of audits requests and denial and appeal activities to determine risk, trends and financial impact. Develop best practices.
9. Participate in revenue integrity focused initiatives as assigned.
10. Perform all other duties that may be assigned in the best interest of Shirley Ryan AbilityLab.

REPORTING RELATIONSHIPS

1. Reports directly to the Chief Compliance and Privacy Officer

KNOWLEDGE, SKILLS & ABILITIES REQUIRED

1. Knowledge of rehabilitation process and care delivery.
2. Professional level of knowledge obtained by a Bachelor’s degree or higher in a specialized field: Physical Therapy, Occupational Therapy, Nursing or related field.
3. Illinois license or certification in one’s own profession.
4. Minimum of five years of clinical experience required, rehabilitation environment strongly preferred.
5. Knowledge and understanding of Medicare and Medicaid regulations and reimbursement.
6. Knowledge of clinical documentation guidelines and CDI program implementation experience preferred.
7. Auditing experience preferred.
8. Knowledge of coding guidelines preferred.
9. Strong writing skills
10. Strong communication, interpersonal and organization skills. Detail oriented.
11. Advanced reasoning and problem solving skills required for data analysis.
12. Must be able to work independently, prioritize tasks, and problem-solve

WORKING CONDITIONS

1. Normal office environment with little or no exposure to dust or extreme temperature.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

SRAlab is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.

#LI-MP1

Required Skills Required Experience

通过收集、分析和解释量的和质的信息来发现并理解问题和机遇；通过建立明确的决策标准、制定和评估替代解决方案和及时决策来选择最佳行动方案；采取符合当前事实和限制条件的行动，优化可能发生的结果。

通过一种易于参与的方式将信息和观点清楚简洁地传达给个人或团队，帮助他们理解并记住所传达的信息；主动倾听他人的意见。