Plans, implements and maintains the RRH corporate compliance program to ensure the healthcare systems compliance with Social Services Law §363-d, 18 NYCRR Part 521, and the Federal Deficit Reduction Act. Establishes compliance operational standards, policies, and procedures and designs improvements to internal control structures to cultivate an effective compliance program. Promotes a culture that fosters ethical and compliant behavior. Advises employees and agents of the health system by analyzing and interpreting federal, state, and local laws, regulations, and contract stipulations. Prepares and presents quarterly reports for the Chief Compliance Officer (CCO), Executives, and the Audit and Compliance Committee of the RRH Board of Directors. Evaluates reports of suspected non-compliance and conducts investigations into potential fraud, waste, and abuse. Prepares and submits disclosures to government agencies under the direction of the Chief Compliance Officer in order to resolve payment discrepancies. Enhances organizational reputation, protects assets, and minimizes financial risk.

ATTRIBUTES

• Bachelor’s degree, MBA, JD or CPA preferred
• 10 years of corporate compliance leadership experience
• 5 years of coding experience with evidence of progressive increased job responsibility within the revenue cycle

DESIRED ATTRIBUTES

• Comprehensive understanding of healthcare revenue cycle, clinical documentation standards, coding and payment systems
• In-depth knowledge and experience with compliance auditing, and interview and investigative techniques
• Ability to coordinate and facilitate investigations and major projects amongst colleagues, physicians and team members.
• Exemplary interpersonal and training skills
• Demonstrated experience in the area of law, regulations and guideline interpretation

REQUIRED LICENSURE/ CERTIFICATION SKILLS

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS)
• Certified in Healthcare Compliance (CHC) or equivalent

RESPONSIBILITIES

OPERATIONAL LEADERSHIP. Establishes strategic and operational plans for the department targeted at ensuring compliance with the Social Services Law §363-d and 18 NYCRR Part 521 mandating effective provider compliance programs; and the Federal Deficit Reduction Act. Develops and implements an annual work plan for review and approval by the Chief Compliance Officer and the Audit and Compliance Committee of the RRH Board of Directors. Develops annual department budget

RISK ASSESSMENT & AUDIT. Conducts an annual risk assessment of organizational compliance risks. Advises employees and agents of the health system by analyzing and interpreting federal, state, and local laws, regulations, and contract stipulations. Provides direction to compliance team members regarding audits of the revenue cycle including, but not limited to, clinical documentation, electronic medical record work flows, registration, coding, charging, billing, payments, denials and appeals, medical necessity, financial statements, payments and attestations, grants, research, RRH employees and contractors for governmental exclusions and payment agreements.

TRAINING & REPORTING. Prepares and presents quarterly reports for the Chief Compliance Officer, Executives, and the Audit and Compliance Committee of the RRH Board of Directors. Prepares and implements annual training and educational programs for employees, agents, and governing body members on Federal and State False Claims Act, Federal Fraud, Waste and Abuse and fundamentals of an effective compliance program per federal and state guidelines.

POLICY & PROCEDURE. Develops and maintains applicable policies such as the Code of Conduct, Prevention and Detection of Fraud, Waste, and Abuse, and Conflict of Interest. Maintains and directs Departmental Compliance Committees. Develops and maintains methods of communication with the compliance function for employees, agents and board members: Facilitating and managing the system wide Compliance Hotline. Advises RRH operations in design and optimization of the electronic medical record in areas of clinical documentation, charging, coding, billing and work flows, which impacts reimbursement and compliance. Oversees administration of RRH’s Conflict of Interest Policy. Directs activities related to conflict of interest evaluation and management, including

INVESTIGATIONS. Directs and conducts internal investigations of reported and otherwise identified non-compliance related to fraud, waste and abuse. Assists Human Resources when investigation findings lead to employment consequences to ensure discipline of employees is fair and appropriate. Directs, facilitates and manages external investigations of RRH by agencies such as the Office of Inspector General, Department of Justice, Attorney General, Federal Bureau of Investigation, Medicaid Fraud Control Unit, Office of the Medicaid Inspector General, National Government Services, Centers for Medicare & Medicaid Services, and third-party payer Special Investigation Units (e.g. Excellus, MVP). Ensures cooperation with agencies and represents the system in a positive and professional manner.